Friday, December 19, 2008

Medscape to the Rescue

Medscape calls itself an online community for physicians. They send emails with catchy subject lines like 'Propofol... is it safe for ER procedural sedation?' (that's catchy to me because it is relevant to my practice), then I click on the links and am instructed to sign in so they can gather data on me. Screw that, every time I try I have to reset my password and I was about to relegate the Medscape emails to spam when I saw this one the other day...


EMRs are 'electronic medical records'. I was so mad at this that I actually tried to take the survey that came along with the email, but couldn't sign in, so I'm writing this instead.

Doctors ARE quitting in droves (and cutting hours and refusing call) and NO, electronic medical records are not the answer you colossal idiots; just as betting more at the craps table to make up for your losses is not the answer, just as putting a fresh coat of paint on the house to deal with your termite problem is not the answer, and just as marrying a gay dude to turn him straight is not the answer.

The whole country is smoking pot. We've got our top three automakers begging for a bailout from congress, the congress that mandated them to build cars that no one wants (by imposing restrictions on gas mileage, safety, and then throwing OSHA into the mix), the congress that, almost to a man and woman, has never operated a business.

We've got the UAW costing these automakers tons of money to build in the US and the answer, instead of busting the union, I guess, is to give them a bunch of money. Well, guess what, we are next!

Meanwhile we have medicine, corrupted initially by medicare/medicaid in that those programs began the separation between the free market and what we have now. And we have EMTALA, which is a ponzi scheme about to collapse under it's own weight. We have discussions about how to fix our system, and doctors, along with insurance companies, lawyers, and the government, take it on the chin, but heaven forbid someone mention what the patients must do to save our system (and they are the only ones who can). 

EMRs??? EMRs? I could run an ER for one tenth the current cost to all with paper charts and paramedics, and do it better than what passes for an ER in today's America. Of course, this would put TOFKAJCHAO out of work along with about ten thousand paper nurses and doctors AND put some burden on the patients themselves, who insist on using us as their free primary care clinic, and that's just not kind or tolerant so I'm just hateful and can therefore be ignored.

In the past year I have tried to do just this... to open a clinic, whether in a traditional brick and mortar office, or to start a house-call service, but guess what, I'm not allowed to do it. See, if I see someone in their home and charge them, then they file with their insurance company for my bill, the insurance company will sue me as I do not have a contract with them. Getting a contract with them locks me in to their fee schedules and there goes my selling point, cheaper, better care in your home. Never mind that my bill is 1/10th what it would have been in the ER... never mind. 

Somehow, in spite of the failures of socialism, communism, the great society, welfare, and unfunded mandates, medicine IS a big-government redistribution experiment, and it will not be allowed to fail. So doctors, get ready, our bailout comes in, I'm guessing, five years. 

That sure will be nice. Instead of removing our shackles and allowing competition back into the mix the government is going to shuffle huge sums of money around and put off the disaster as it is doing with just about everything these days. And in the meantime, ER docs are getting so scarce outside of academia and big cities that the locums companies are paying me more than I ever made working for a contract group. The market can be ignored for a while, but when you are having a heart attack the minute clinic won't do you any good, and you better hope that whatever hospital you go to has a cardiologist on call that night (and there is a story here, but it's for another time). 

Meanwhile, sure, buy the $800,000 EMR system for your ER and retrain everybody from doc to tech on how to use it. The process only takes a few months to get going. But, if it's like the one in my last hospital the first thing you will do is turn it off. And there is a big bonus here... the patients no longer have to remember their medical history, "it's on the computer doc, just look it up." A nation of helpless, whiny, entitled, spoiled children, and very few with the balls to demand the freedom and liberty that our country was founded upon. Merry Chrismas.


  1. Huzzah 911.

    While everything you said is correct, you forgot one group who's fault it also is, Physicians. Not you guys, but the worms at the AMA(and other such acronym Doc organizations) and Academia(who commonly push socialist policies).

    Another bubble, almost sure to fail is academia, however, more so in ten years time I believe.

    What will the US Government do? Bail them day, there won't be any foreign nation that will be willing to front the US Government money. That's when the whole system collapses(or at least grinds to a halt).

  2. patients don't have to do anything anymore but show up's not patients rights it should be patient entitlements because rights imply back used to hurt because i actually worked with i have eye strain from computers..being random here but finishing up another wonderful shift making sure our press gaineys stay at a 4 star...say it loud and clear 911 doc..IS ANYBODY LISTENING???!!!

  3. You got that right! Whatever happened to JFK's "ask not" speech that was supposed to become everyone's mantra? I guess it got smoked, inhaled and shot away.

    BTW 911 - an update on my father-in-law and the fluid on the belly. Pathology came back - pancreatic cancer. Less than 1 week left here (most likely 2-3 days) before experiencing great joy for eternity. He will be greatly missed. We really appreciate your insight - it helped point us in the right direction to locating the problem. At least now we have the opportunity to say good-bye and have a final early Christmas with him. Many blessings to you for giving us that gift! God bless you and keep you! And keeping bustin' the govt's and any agency with an abbreviation for their name's chops!!

  4. I hear Jonathan Glauser M.D. will be providing ALL emergency care by 2012....

  5. Medscape is powered, managed, and edited by morons. The same people that brought you WebMD.

  6. Okay... pardon me for being dumb here. But the part where 911Doc said the insurance company will sue an independent doctor for not being contracted with them, if the patient submits a claim? What? Seriously?

  7. 911Doc.... Kudos to you for at least trying to change the system. There are a lot of us out here who be happy (elated) to pay you for your at home services out of pocket and to hell with the insurance company. I want to have the tests and treatments my Doctor recommends not what some paper pusher in an unknown office feels is just for me. I for one grew up with a "Country Doc" who only made house calls. What better way to see the whole picture? And then your rant about the people who use the ER as their primary care? I had a primary who TOLD me to use the ER when the office was closed!

  8. 911 Doc,

    nice rant. If I were to put this in the surgeon's lounge in our local hospital I doubt there would be a detractor. Well, except for the non-practicing doctors in the administration.

    I volunteer in a free clinic. Every saturday we see 20+ patients who would have otherwise have gone to the ER. When I can get a specialist to see these patients and serve them for free, these same patients are the most likely to sue said doctor or to be a demanding cad. I tried to get the local legislator to at least allow Docs to write off their services on their taxes and was denied.

    I keep getting the feeling that someone is trying to wreck the whole system.

  9. Goin out on a limb here, but I've told patients to go to the ER for minor things. Who knows, that ingrown toenail might be Cancer, the Torn Rotator Cuff an early MI, and did you here about that depressed Mailman last week who killed that customer who didn't have exact change?? You didn't, cause he went to the ER at 4am to get his Lexapro prescription, Oh, that was the one I saw in the ER, damn Incompetent Primary Care Idiots!!!!!

  10. I'm with PharmD2B. WTF? Why wouldn't the insurance company simply kick out the bill? I've had them do that to me, the bastards. I know docs who don't accept insurance, so wouldn't you fall into that category?

  11. One of my specialists doesn't accept insurance, and I pay him actual money because he's so good. I admit that he gives me a discount because he likes me and I'm a teacher, though, not a a dotcom billionaire.

  12. When my late father died, we discarded the 40-years' worth of patient records he left behind. He'd been retired for 25 years, so retention for med-legal reasons was not needed. The files consisted of 4x6 cards with (usually) single line entries, so that a single 4x6 card might contain the record of 30 years of visits to my dad's general practice. I would challenge anyone to prove that the care he provided would have been better if documented on an EMR.

  13. nsrgeon,
    thanks. i agree, whether consciously or by devious schemes our system is being wrecked.

    yes, the company would probably kick out the bill but then why would folks come back when they can get care in the ER for whatever their copay is for 'free' even though it comes with a few hours wait. but it IS true that you run yourself into legal problems without contracts with insurers, this was a bit of wisdom imparted to me by the consultants i worked with in my first attempt to start my own clinic. my plan was to go straight fee for service and they laughed. they then produced the data to back up their claim that fee for service clinics have been tried and have all failed, mostly in california, BUT if you want to open a fee for service enema clinic then go to it.

    papa goose,
    you are so right. let's say the EMR is all that and a bag of chips, there is a fundamental flaw in this concept, especially true for ER physicians, and here it is. the selling point of an EMR is efficiency. docs would, theoretically, have the patients entire medical and surgical history at their fingertips at all times. that is, at all times that the computers are working and the internet is up and HIPAA is not hot on the case. but this assumes that doctors want to work faster and see more patients. in the ER we certainly do not want to do this. seeing 2.5 patients per hour is considered 'fast', Oldfart can probably see 3.5 to 4 an hour without batting an eye but that's what comes with decades of clinical experience. clinical experience is not factored into the EMR, having a patient's entire medical record in front of me assumes a. that it contains no errors and b. that the information in it is relevant to the current complain.

    when someone comes in with an MI there's not much in the medical record that changes a damned thing i do because the government or TOFKAJCHAO standard is to get the patient from the door of the ER into the cath lab in thirty minutes or less. besides being well nigh impossible on it's face, adding an EMR and all it's bells and whistles here means nothing, if anything it delays care.

    finally, having an EMR assumes that medicine is all science and no art. some patients, especially psyche patients, require more time than others, time at the bedside, time judging a whole host of secondary factors and putting the whole puzzle together in a few minutes. the EMR for the ER adds nothing here except a false sense of security.

    for example, until about a year ago we were putting a lot of weight into recent cardiac studies like stress tests and especially caths. a recent clean cath meant that the pain was not cardiac, the end. then tim russert dies of an MI a month or two after a clean cath. turns out that many coronary plaques are intimal, meaning within the coronary artery walls, and are not visualized by a cath. scary, scary, scary for us in the ER.

    unlike other branches of medicine, with, perhaps a few exceptions (trauma surgery for instance), THE proper way to practice emergency medicine is to think of the WORST POSSIBLE DIAGNOSIS that would explain the patient's symptoms. again, in the chest pain example, standing in front of a jury explaining that you sent MRS S home because 'statistics have shown coronary disease to be less prevalent in women of her age and the EMR said that she had a clean cath three months ago' will render a verdict for the plaintiff. period.


  14. f*ck yeah, 911. Seriously, this is a candidate for rant of the year.

    I encourage all the docs who frequent a physician lounge to print out several copies, and anonymously leave them in plain sight. Merry Christmas, indeed.

  15. 911,

    You've actually touched on something I've been pondering recently, How much of medicine(also been thinking about Math as well because my father is a mathematician) is art. Through my interactions as a patient, I've always found that older physicians are just better physicians on the whole. Even though it's only anecdotal, I believe that it shows that medicine on the whole still is as much an art as it is a science. And while medical science progresses, I don't believe it's making much progress in eliminating the art of medicine. The day science eliminates the art(which I believe will never happen) is the day when someone could make a computer a Medical Doctor.

    It just won't happen.

  16. Disgruntled Internist5:35 AM, December 21, 2008

    So, primary care doctors are leaving in droves and EMR is the solution?? WTF?

    I've got the solution. How about paying us primary care doctors more than 27 cents on the dollar??

    WTF??? Seriously.

  17. Medicine as art..WTF..Of course a lot of it is. Yes, I can see
    3-4/pts/hr but my PG's go to shit, (not that I care) It's a walkin gut feeling this one's sick or not sick.

    I try to teach my residents this way. Don't bring me a differential list of 10 possible diagnoses. Instead, tell me 3 things after 5 MINUTES with every pt and 80% of the time you'll be right..I let the other guys run down the differential dx list..

    1) Pt is sick or not sick
    2) Pt needs hospitalization or we can fix them in the ED and discharge them
    3) We can fix them or we need a consultant's help

    That's "art" It's a gut feeling. It actually comes very soon in a doc's training. You either have it or you don't and it's not easy to "train" into someone..

    Main ED Axiom: Sick or not Sick!!

    In the ED(my apologies to my friends from other specialties who might not understand or agree with this but it's the truth)
    We should be very "sensitive" to illness not "specific" I don't give a shit if the pt has a Pheochromocytoma, Rabies, Blastomyassoma. They are sick and need to be in the hospital to find out what's wrong. You can order the exotic tests, I don't care about the glory. I don't need to know what the T4S7M2 urine level is!
    That's our mission and to be the pt's advocate when needed..

    EMR?? Who the phuck cares. As pointed out above, it's only available when the GD computer is up and running, you can get to the internet, etc.

    Bite me, Press and Gainy...

  18. Oldfart, I think you nailed it square on the head with that last comment!

    And re: "blastomyassoma", I just about busted a gut laughing over here! My thought is that this culture of "get 'em in, get 'em out, 'cause we don't want to be paying for all this stuff" has resulted in docs with less refined clinical skills, which of course winds up being bad for patients. You'd be a good one to learn from if I was a newbie doc.

  19. The 'sick or not sick' is a skill learned in pre-hospital care as well. After 10 years as an EMT, I've learned when I should be hauling ass in to definitive care, and when I can take my time. Granted, it took a bit of time, but once my call-volume starting increasing, that skill/art came with amazing speed.

    Some people got it, some don't, and as OldFart said, it can't be taught. Why you have some docs (and medics) ordering every test in the book just in case...

  20. oh c'mon guys evidence based medicine is the GOLD standard...the art of medicine died with the dinosaur. read malcom gladwell's book about what good practioners of about everything really do... INTUITE. I guess that's a dirty word nowadays

  21. I like what you said, but you're flat wrong about the union. You forget that a union contract is 50% union, 50% GM or Ford or Whoever. They agreed to the contract, so I don't want to hear a bunch of pussy whining.

    The fact that banks bilked this country for billions to take fucking spa trips and foist over to stupid cunt execs was never the subject of congressional bitch sessions like the auto makers. What it amounts to is some good ol boy southern fucktards who like their Toyota and Honda plants more than they really will admit publically.

    Fuck American companies and Fuck the Unions while we're at it, just keep my Toyota contributions coming!

  22. Excellent post 911 Doc!

    Btw...I think it is admirable that you would consider house calls. It would limit your available time though.