Tuesday, July 08, 2008

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.


  1. I am going to cautiously stay out of the "Canada discussion", but otherwise I agree with you that this a blatant abuse of the system.
    However,ER being for emergencies, why do you not turn down people who do not have one? Would that be illegal?
    Also, are men ever diagnosed with fibromyalgia?

  2. dear amy65-c,

    we have tried to find a way to winnow out the non-emergencies but have failed. the reason is that being in triage is the hardest job in the ER for nurses, and it is often done by nurses who can't do their regular jobs. also, getting into screaming matches with patients out in the waiting room is considered poor customer service.

    the tirage job is better done by a physician or a midlevel with lots of clinical experience and accumen but this is not cost effective nor is it good... customer service.

    there is also the phenomenon of 'historical alternans' where the patient's complaint morphs from 'pulled muscle while lifting couch' to 'chest pain' between triage and a bed in the ER. it's why, when you are a patient, you get asked the same questions five times... we can't afford to miss anything.

    folks who know the system know that all they have to do to get right back to a room is say 'chest pain' or 'numbness' and they're in.

    also, there is the zebra phenomenon, and no one wants to be the one to miss a zebra. miss a zebra and you are in court, and, we have at least one a day. as long as the standard is what it is, the safest thing for doctors and hospitals is to see everyone.

  3. We watched this movie yesterday while #3 was coming out of anaesthesia--knocked out four front teeth in a bike accident. Apparently it's even funnier on drugs. And while the oral surgeon was giving me follow-up instructions #3 kept smiling and grabbing my ass. He remembers nothing of this (-:

  4. Hey Devo, would diverting the rounded off fractions of a cent to your own personal account really be stealing? Just Wondering.

  5. Nah--it's only stealing if it would benefit the whales or orphans or sumthin.

  6. 911doc is making one, inarguable point: nothing comes from nothing, and if you try to squeeze something out of nothing, you end up with nothing.

    How sad that this has to be explained.

    Best wishes, 911doc. I pray that most of the days before you are happier than some of the days behind you. However, you will be dearly missed.

  7. Hey now, I can usually differentiate between BS CP and real chest pain with my mad crayzee question-asking skillz. People know to say "chest pain", but they're not sure if they should say it hurts worse when they walk or worse when they breathe or if it's stabbing or achy or sharp or dull or whatever.

    And it's not just the layzees sitting out at the desk---we all (after you're experienced enough) have to rotate out there, at least where I am...

  8. There are still some good ERs out there, 911, but your hospital sounds really dysfunctional. I hope you enjoy your new gig.

  9. stranger in my own country11:23 AM, July 09, 2008

    "Ahmed"?? What country are you in, where I live the average freeloader has a name like Jose or Chaquita.

  10. /sticks her head out of her hidey-hole

    speaking of chest pain: anyone have any suggestions for memorizing what is happening on an EKG with the mechical/electrical/pressure volume changes that are occurring in the heart? Wigger's diagram is going to give me a heart-attack.

  11. This is why I am leaving. More BS mandates from those who do not practice medicine.


    I am sick and tired of the circus bureaucrats have turned medicine into.

  12. Hannah, don't worry your pretty head over that stupid diagram. Its worth maybe 1-2 questions on the boards max. Not thats it not important, and I didn't have that much trouble with the heart(my weak spot was those pesky female hormones, I still have to look in the PDR everytime I prescribe OCPs)but don't waste time on stuff you don't understand.

  13. Tsch! What's hard to understand about female hormones? All they need is a little wine-ing and a little dine-ing...voila!

    I just find it obnoxious. Like memorizing the cranial nerves. But at least the cranial nerves had fun little songs to go along with them.

  14. hannah,
    if you are talking about the diagram that relates the ekg to the actual pressure situation and valvular mechanics of the heart i've never heard of it. haha, in all honesty, it's important if you are a cardiologist or a physiologist but otherwise it's just a 'hoop' question/graph.

  15. The problem being that I'm an undergrad in physiology who is finishing the last of her pre-reqs. If I do poorly on this test, I MAY GET A B IN THE CLASS. :O :O And then, my life will come to an end. Obviously. Duh.

  16. I would love to have a private ER in my town. I hate going to the doctor and seeing people with medicare and medicaid suck up resources that I know my insurance is geting fucked over for.

    I also hate going to the doctor and having to listen to shitbags piss and moan that their free state paid care isn't good enough while I'm paying an ass load. It's like you could give these fuckers a gold ingot and they'd bitch that it wasn't shiny enough.

    So yeah, I'd like to see a private ER where I didn't have to walk past that fucking "You have a right to emergency care, including care for an unborn child, and transfer to an appropriate facility if necessary" wasn't slapping me in the nuts on the way into the hospital.

  17. Actually I think private ERs are a GREAT idea and I agree with anon. It's all about entitlement. I am all for EMERGENCY care when you need it. However, going to the ER for a pregnancy test/gas/ whatever minor thing is NOT appropriate. I got a chuckle the other day while at the orthopedist. I was sitting down while waiting to be called back (I'm a private insurance patient). A guy had been to the ER and he had an ace bandage on his foot. Could walk without crutches and everything. No limp or anything. Anyway, he went up to the window and asked something. So then he came up with a new problem that needed to be seen. The receptionist said sir, that is a not a problem that you were referred from the ER with. We do not take medicaid. We only take medicaid for referrals from the ER. We can only see you for the problem that the ER referred you for. You are welcome to pay for an appt for the problem that was not ER related. He was NOT a happy camper. Needless to say, he no longer needed to have that issue evaluated.

  18. Have you not yet met the mouse? At my academic hospital JCHAO and press ganey weren't enough...we're disneyfing.
    Mind you, not enough money to give the nurses a raise but enough to fly 180 managers to Disneyworld.
    We've learned how to point!

  19. If you could only replace that printer with Deborah Peel...damn it would feel good to be a gangster.

    If you relate the ECG waves to where the wave of depol. is happening anatomically, you figure it out pretty easily from there (ie: p-wave=atrial depol.-->atrium is contracting-->increased atrial pressure-->opening of mitral/tricuspid valves-->isobarometric filling of ventricles. Insert more/less detail as needed.) This way you actually learn the material instead of drawing out a stupid diagram.

  20. Ahh yes, the Mouse-ification the ER. Next to Disneyland, the ER is the happiest place on earth. After the time spent in the customer satisfaction re-education gulag..I mean Customer Satisfaction Camp I hum "It's a small world" to work. I found seeing patients in the Goofy costume a little too cumbersome to do things like chest tubes and intubations, so I chose the Thumbelina costume. Not many 6 foot 1 inch males with hairy legs can really pull it off, but I find the costume has a certain liberating flow. Besides, as soon as the hospital completes the adjacent amusement park, I can give free tickets to all the children that find me scary.
    And you thought the only thing that comes from the Mouse was hantavirus. Well, turn that frown upside down. Gotta go, cause me and Minnie got to turn a code into a satisfied customer of the Enchanted Kingdom...

  21. I had to hand out Customer Satisfaction Cards when I had my paper route at age 14. Filled em all out myself, even went through the trouble of changing my handwriting.

  22. people pay to go to disneyworld.

  23. drack,
    since i am leaving i think my patient satisfaction forms (not press gainey... the ones we hand out) will get really good all of a sudden. thanks for the idea.