Monday, January 12, 2009

The Lack of a Liberal Arts Education

I do not know the author of this piece in EP Monthly and bear him no personal animosity. The fact that it was published at this time seems to me to be an alarm-call about what is to come with our health care system.

A friend of mine has written a rebuttal, and has been rebuffed in his attempt to get it published, so I am including it below in full.

Notice, if you will, that Dr. Hochfeld demonstrates a few things in his apparently dispassionate plea for a government fix. The two that strike me are the logical fallacies that run throughout, not the least of which is an amateurish and shallow view of what a 'right' is and what a 'right' means in this country, but moreso, the fact that if one does not accept his initial premise, that 'basic health care is a right for all' that the rest is pap.

I do not accept his premise and neither does the good doctor below. Dr. Hochfeld's 'solution' to our 'crisis' would have been lauded by Marx himself, but this doesn't appear to bother him or those who responded favorably to his proposal. It is unconstitutional on it's face, also, apparently not a big deal for the author or for our president-elect.

I weep for the people of this country as Che-Guevara-esque portraits of Obama are being posted in the hip cafes of this great land. We are witnessing the birth of a cult of personality. Without further ado, I present my friend, Dr. Tarkovich, a boarded EM physician with a tour in Afghanistan under his belt and a knowledge of history and logic that destroy Dr. Hochfeld's arguments like Oprah destroys a doughnut.
I want to comment on Dr Hochfeld’s article on health care reform, as I see some major flaws with his reasoning. I think the problem that most people have when trying to solve the high cost of health care in this country is that they have trouble stepping outside of the current paradigm. Free market health care would not work within the current system, but where is it written that the current system cannot be changed?

First of all, people do not have a right to health care. Dr Hochfeld claims that “access to basic health care is a right,” but then goes on to say that certain physician services are included in that right. There is no way that a person can have a right that infringes on the rights of other people. These are called positive rights, and are morally flawed. A person can have a negative right- the right to be free from harm by another person, but health care requires that other people provide goods and services. If I have a right to health care, the doctors, nurses, pharmacies, and drug companies will have to give me their product and service for free, which infringes on their right to be compensated for their labor. What do you want to do to people who refuse to give away their work for free? Steal money from them in fines? Put them in a cage? Once you force someone to work for free, that person has become a slave, which is prohibited by our Constitution. Claiming that people should have a right to health care is akin to saying people should have a right to food and therefore all restaurants and grocery stores must give their products and services away for free. Is the government going to pay for these things? How will they ration those dollars and determine who is deserving? Will they also throw money at another commission with a top-heavy bureaucracy? What if a physician does not want that money with all those strings attached? Is he or she free to make those decisions, or is the doctor forced to provide that service on penalty of being fined or jailed? The socialist system cannot work without threats of violence. Am I the only one who finds that troublesome?

Dr Hochfeld makes the argument that the suppliers of health care have too much control over the demand. I agree with him, and this is where the free market could take over. Why does it cost $800 for someone to come to the ER for an uncomplicated broken arm or laceration repair? Why can’t someone spend 6 months to be trained in simple procedures and make a living in his or her own private clinic? No, there is no medical degree being given, but they can let the free market determine if they are doing a good job. They have a great incentive in that they will go out of business if they do shoddy work. Before you suggest a regulatory body to oversee this industry, think about how much the costs will go up to fund the bureaucrats in this endeavor. We are trying to keep costs down, and the free market is very good at that job. I am sure these people would be happy to receive $50 for minor cuts and breaks, and they could even use dangerous drugs like: lidocaine, tetanus boosters, and cephalexin. We have a monopoly on services in this industry, and the free market cannot exist without competition. What would hospitals do to compete with this new sector? They would have to lower prices. If a person wanted a thorough physician evaluation, he or she could choose to pay more. Much in the same way you decide what to eat for dinner or what type of television to buy, cost plays a role. People make decisions about their health based on cost all the time (types of food, cigarettes, alcohol, saturated fats, etc).

Additionally, Dr Hochfeld proposes a system with a salary cap for specialists. This is akin to complete socialism without allowing market forces to determine salaries. Karl Marx’s “labor theory of value” says that value is determined by the amount of work required to produce a product, not the consumer demand. This fallacy means that a surgeon who labors for six hours and finally removes an inflamed appendix should get paid more than the adept surgeon who removes it in 30 minutes. Guess which doctor will have more consumer demand and be worth more money in the free market? When we try to fix things with central planning, we are marching down the same road that caused the downfall of the USSR. No central body can ration health care dollars because no one can predict market pressures and respond to consumer demands as rapidly or as efficiently as the free market. In order for our system to work in the free market, we would have to remove the current restrictions that allow for monopoly privilege of physician services. Dr Hochfeld claims that he is looking for a way to make physicians work harder; the answer is competition.

Pharmaceutical companies are also hampered by FDA restrictions, which make them take almost 20 years to get a new drug approved. They in turn have to charge ridiculous amounts of money for their product to recoup these costs and strategically hold off on releasing medications until they have exhausted the prior one. For those of you who will argue that this is for safety, I urge you to look at the number of drugs that came to market and were later found to be extremely harmful. What is wrong with publishing data and allowing physicians and patients to decide? Are we too stupid to make those decisions? How long would a drug company be in business if they produced a drug that harmed many people? No one would buy his or her product and the owner could be held liable in court as well. When was the last time a member of the FDA got sued for approving a drug that was harmful?

Finally, on the issue of care for those who need it and can’t afford it, I bring up the absurd notion of “charity.” We are all human beings, and most of us in this line of work have compassion. Personally, I donate a large amount of money to charities every year; charities that I feel do an excellent job. For those of you who think the government is the best charity to handle this endeavor, look at how carefully they handle your money and how efficiently they produce things like new roads and highways. Do you want more “evidence-based” medicine like blood cultures in uncomplicated pneumonia? (Hopefully the sarcasm came through in those comments). The free market would do a much better job of caring for sick people than our current socialist system. Wouldn’t it be great PR for a hospital to have an entire charity wing? I think a doctor would acquire many more patients when it became known that he or she spent even one day per month doing free care. Of course, the legal system would have to be drastically revamped in my world, but that is a topic for another time.

When the system you propose requires that you use a word of violence like Tsar, it is time to rethink that system.


  1. Wow..... very well written. Spread this far and wide!


  3. Couldn't of said it better myself.


  4. Couldn't of said it better myself.


  5. wait a minute... i take it all back... i just found out that dr tarkovich is a jew.

  6. I've been reading this blog regularly since discovering it a couple of weeks ago. Thanks to those who maintain it and contribute to it for both the education and entertainment I've gotten from it.

    Here's a question for the group- When (and why) did our country become run by lawyers? Our country was founded by great military leaders. Most of our nation's presidents and prominent politicians were former high ranking military. This seemed to go out of favor some time during the 20th century after Teddy Roosevelt and Eisenhower. The recent book "AWOL" points out that in 1971, three-quarters of our representatives had military experience. Now, fewer than a third do, and that number drops with each passing year.

    With these changes at the highest levels of our government, there has also been a general philosophy shift in the country. As numerous posts have pointed out, we now live in a culture of entitlement and "who can I blame/sue?" when anything bad happens. And the ultimate beneficiaries of this philosophy are lawyers.

    I went into medicine thinking it was a noble profession. I thought I would be insulated from the heartless, unfeeling litigous aristocracy that pervades the US. Then I come to find out that the government is run almost exclusively by lawyers. They make all the laws that determine how Medicare/Medicaid work. They run all the insurance companies. And they will also be more than happy to question your entire life of medical experience any time someone you have seen has had a bad outcome whether or not there was a medical error.

    Perhaps Shakespeare was right when he wrote "The first thing we do, let's kill all the lawyers". Unfortunately, that's probably a little too extreme. Anyone have any better ideas?

  7. I've got an idea...LOSER PAYS. If there is no disincentive to sue, then sue we will. 50,000 filed in the U.S. every day.

  8. Like it or not, we need lawyers. However, the judges who allow them to file suit needlessly are the ones to blame. Many lawyers and their clients should be laughed out of court by judges, on a daily basis.
    The reason this does not happen is of course politics.

  9. quibble: the Shakespeare quote re: lawyers is always taken out of context... it was said by a villian as a method for destoying the stability of a society.

  10. Can't blame the Lawyers, they're just doin a job, like a Bird of Prey or Maggots... its the Expert Witnesses I'd like to see lined up single file and executed with single gunshots to the head,their rotting corpses hung up at the City Limits to warn potential Expert Witnesses of what happens to those who break the CODE... and I've never even been sued..

  11. Interesting comment about Expert Witnesses. But aren't they paid by, and therefore exist solely because of, lawyers?

    And aren't most judges former lawyers? Your point is valid, though, that the root of the problem is with "the system" and not necessary a particular group (ie- lawyers v. patients v. judges v. legislators, etc).

    A "loser pays" system would be great, but if people can skip out on medical bills should we honestly expect people to pay legal fees? Perhaps the lawyers would find a way to make that happen.

  12. No. It's not lawyers, or expert witnesses. The problem lies with the concept of a jury of your peers.

    Most people are morons, which is why a grade of C, on a test, means something like a 70% correct answer. If you will accept that true fact, and that everybody else amongst the great Average is likely to get the answer wromg even more often, you have the modern jury.

    Neither P.T. Barnum, nor Johnny Cochrane got poor, betting on the folks that American Idol gets rich upon. Juries of our peers are now juries comprising the dumbest, least well informed, least apt to be otherwise released from jury duty.

    In my mind, this is the problem: well informed people avoid jury duty, and when they do not, are dismissed from the jury pool by attorneys from both sides.

  13. Now, I'm not anywhere as down on lawyers or the people as most.

    However, I do think our society has lost an ethic that we use to have in years past. What the people have lost is not intelligence, they're more intelligent than ever. It's character, we lack the personal responsibility of yesteryear. Also the chaotic and changing legal environment doesn't hurt either.

    Finally, the government has learned that they can rob Peter to pay Paul. Even though it isn't as bad as when FDR was around.

  14. Lawyers would make people pay, because unlike us there is no federal mandate that they must see them. They would at least get a large retainer fee if they felt the guy may skip out if they lose. We don't have the luxury of getting a retainer fee. I'm not sure everyone saw my comment...50,000 lawsuits daily....50,000.

  15. That is ridiculous and because I am opiniated, I insist that 45,000 of those should have been dismissed the judge.
    Other countries do it, why can't we?

  16. I agree with Roman Wolf that there has been a fundamental philosophical shift in the US. Stories of early American history are steeped with "pioneering spirit" and "rugged individualism". Nowadays, we hear of people constantly trying to place blame and responsibility on anyone other than themselves and this philosophy has been reinforced by the legal system (eg- suing tobacco companies or fastfood restaurants for health problems). Legal reform as suggested by Dr. Tarkovich, Amy-65C, and shrodinger's cat is clearly needed.

    I am optimistic, though, because the self-reliant American ethic is clearly not dead. It's merely being drowned out by the incessant whining of those who refuse to accept any personal responsibility. If it was dead, then every accident and injury would end in a legal process of some kind. This tells me that there are a large number of people out there who understand that sometimes accidents happen and there truly are circumstances that are outside of anyone's control. I only wish this group could become the vocal majority and put an end to the "it's not my fault, so someone else should have to pay" culture we now live in.

  17. I broke my elbow 2 years ago while rock climbing at an indoor gym, which required a trip to the ED (making sure that it wasn't completely FUBAR'd). A month after that ER visit, I received a letter and survey from some company in MI, asking what had happened, was it an accident, and did I feel that it was anyone's fault. I was insulted that the majority of the questions seemed to be leading towards a "it was their fault, you should sue" kind of attitude. When I didn't respond, I was sent several more, until I finally did respond.

    Same thing happened when I had surgery this summer, to correct a shoulder issue caused by the same fall. Again I was contacted by the same exact company that had sent the first letter. Again, I was insulted by the idea that I should be forced to fill out this survey so that some lawyer could review it to see if there was a possiblity of a case.

  18. Roaming Gnome, insurance compaines have started to do this because they don't want to pay for your care. I have heard that some will sue on your behalf even if you won't to get someone else to be at fault and cover the bills. It's sick.

    Hasn't anyone ever had the insurance company call and ask if you feel your injury is someone's fault or the result of negligence on someone's part?

  19. Amy and Gnome,

    The insurance companies pay a contractor to audit their claims for any claim that might be the fault of a third party. If an injury is caused by another person they will then contact that person's carrier (home owners or car insuranc if accident, employer) and coordinate benefits.

    If another person is at fault and the person at fault has insurance that covers this situation is there a moral reason why their insurance company shouldn't pay?

    It's not in the financial best interest of the insurance company to spend thousands of dollars suing an individual as RIAA is rapidly finding out. At the very worst it is your insurance company suing the other insurance company.

    Having the car insurance company of the fellow that hit you pay for your medical claims is one way of reducing "total claims paid" by your Health Insurance Co. and thus premiums for everyone.

    You should no more be insulted by their questions that you interpret to mean that "you should sue" than you should interpret the intake question at the hospital "Does anyone in your home hit or yell at you" to mean that you should spend that night in the nearest battered women's shelter.

  20. Just a quick note: "Tzar" is not a word of violence. It is actually a reincarnation of Caesar, meaning leader, and was the title of the royalty in Russia, who were overthrown by the Bolsheviks. It has been given a connotation (a meaning conveyed through feeling, not from a legitimate reference, like a dictionary) that is negative because of the title "Drug Tzar," which refered to leaders of illegal drug organizations. The word "tzar" was used by the media to tap into the latent fear of anything Russian, therefore Communist, that has infected our country for nearly 100 years.

    Like 911 Doc stated at the beginning of his or her post, I hold no animosity towards the author of the article, though I will extend this to the authors of both articles. I simply hate to see words be victimized for something that wasn't their fault.

  21. A question from an economical moron:

    Doesn't this devotion to the free market seem misplaced, especially in these days when large enterprises - founded within this same free market - have now become "too big to fail" and requiring public funds to support? Its a disastrous situation, and one that occurred in the environment of this free market that our 2nd author clings so tightly to.

    Isn't health care a little too important to be left out in the breeze of the free market? I mean, if my local pizza restaurant makes some bad business decisions and goes under I'm not so worried. If the same thing happens to health care in my area, its a bit more of a problem, no?

    Medicine seems to me to be too important to be subject to the wild swings so characteristic of a totally free market. Competition ensures survival of the fittest, but it definitely does not ensure stability. Not the kind we need, anyways.

  22. For some reason I couldn't get the link to load, but as for positive rights we have those. Right to safety requires law enforcement hence requiring someboydy to be there to enforce the law. K-12 education requires that somebody teach the children. Healthcare can be very similar with both public and private elements as exist in eitehr of the above two. Penalties for not providing a service? none - these folks sign up for a job just like any other and are free to quit if the want.

    The free market mantra is itself flawed. It leads to the trusts and monopolies that dominated businesses in the 1800's. Not that pure socialism is at all better, but both must exist in balance for a society to prosper.

  23. Anonymous economical moron (your self-given title, not an insult)-

    I assume your first point is referring to the auto and banking industry. Neither of these ventures have been subject to the "breeze of the free market" in the recent past. For example, union contracts have GM paying line employees $70+/hr (how many docs out there make that?). And the banking industry has been insured (ie- FDIC) for decades. So why should a high level executive take a salary cut or give up a private jet in order to improve a companies bottom line when the assumption all along was "the government won't let us fail." So I disagree with the assertion that since both these areas are currently failing, it is because the concept of a free market has failed and thus the same would happen to the health care industry if it were privatized.

    Your second point is that "health care is too important." Several candidates ran campaigns on the slogan that "health care is a right" even though many previous posts have dissected the Constitution and have yet to find such a right explicitly stated. Even if you accept that health care is a "right", when you're dealing with a limited resource such as medical professional's time and health care dollars, then there must be an agreed upon basic standard that must be met. For example, there is a Constitutional right to an attorney. But that doesn't mean I can demand that Alan Dershowitz defend me (for free) from my speeding ticket. Having access to a doctor, vaccines, and standard-of-care (another tricky term) medical screenings should fall under that "right". But presenting to an ER with a toothache that has been there for weeks simply because you can't afford a dentist but the ER is "free" certainly would not.

    As physicians, we try to do the most good for the most people that we can possibly accomodate. We sacrifice time, money, and personal lives all toward this duty that we feel to help our fellow man. But many of us are seriously questioning these sacrifices. We see patients who are blatanly manipulative and purely drug seeking. We see patients who are unappreciative no matter what lengths we go to in order to provide them care. We see patients who take no responsibility for their own health like the smokers who can't understand why they cough or the obese patient who can't understand why he has back and knee pain. We argue with patients constantly who have been told by their families, friends, or chatroom advisors that they need X, Y, or Z test/treatment when there is no medical indication whatsoever. When these interactions end with a payment of 30% or less of billed services, you should see why physician satisfaction is suffering.

    Bottom line- a mentor once told me "You can treat me bad and pay me well or you can treat me well and pay me bay. But if you both treat me bad and pay me bad, I'm going to find somewhere else to work." I think this is the underlying theme to this entire blog.

  24. Anonymous #2-

    Excellent point about positive rights already existing for law enforcement and education. However, in both those cases there is an agreed upon minimum standard. If someone desires more security, they are free to buy home alarms or their very own security guard. If someone feels their child needs better than the local public school education, they can hire tutors or place the child in private school at their own expense. The difference with health care is that most people have the expectation of highest level or care delivered immediately at a cost that they (not the physician or the hospital) determines based on their perceived ability to pay. I say "peceived ability to pay" since many who can't afford to pay their own medical care can still afford cigarettes or eating out on a regular basis or cell phone plans with unlimited texting.

  25. I see the point of many of the ideas advocated in the featured article, but to promote the dissolution of regulation in pharmaceuticals and the proposed non-MD-run clinics seems a little steep.

    It is true that the free market can wade out such problems, but not before a few poor saps pay with their lives or livelihoods, which seems to be the primary reason for regulation.

    Not only that, but it seems easy to imagine how quacks and placebo cures would abound even more than they do nowadays, in absence of a defining standard.

  26. dear yoshi,

    snake oil will always be with us. i am reminded of three recent scams that evidently brought in millions..

    1. 'head on' apply directly to head!
    2. colon cleanse, to get all the 'spackle and paste' out of your colon, and...
    3. airborne, cold and flu prophylactic

    all shit.

  27. Glad to see the rebuttal made it over the original source of this "well-meant" but ridulous piece of tripe. I have nothing of value to add except my profound thanks and permission to quote and circulate this brillant reponse to the throngs of bleeding-heart, warm and fuzzy nurses I work around! Pattie, RN

  28. 911-I still laugh when I think about those head on commercials. Just because you say something 3 times in a row does not make it true! (something I tell my kids when they tell me things I know are not true and then repeat them over and over thinking it will convince me).

  29. Dr Dave,

    You say:

    "...However, in both those cases there is an agreed upon minimum standard. If someone desires more security, they are free to buy home alarms or their very own security guard...."

    Isn't this fairly similar to the system we have currently? Uninsured drug abusers looking for rehab get a specified number of days in the clinic before they are kicked out. Emergency departments are required only to give a medical screening and stabilization prior to consideration of the finances.

    I am far from an expert but it seems to me that there is a definite level of care than an uninsured/nonpaying patient can expect to receive, and then there are additional levels that require supplementary insurance or payment.

  30. anonymous,

    you are both correct and incorrect.

    the uninsured, a large majority of whom have managed to budget for cars, cigarettes, cell phones, professional sports tickets, and food, find it hard to get definitive care for non emergencies.

    however, if you are a skid row alcoholic and are having an MI and, it turn out, you need a coronary bypass, you will get it.

    in fact, if we DID have a two-tiered system de jure rather than de facto much of the 'crisis' would be gone.

    example: i recently had occasion to speak with a woman from new zealand. she was in the ER with her dad who had just suffered a new onset seizure. he was admitted. she and i spoke and she said how much she loved he NZ system, ''all you have to do is pay $40 and you can see a doctor anytime".

    so NZ, 15 years ago a one payer system, has come back to a logical position, basic health care as a 'necessity' for all, and if you want your health care done more quickly and with less red tape then you may purchase supplemental insurance.

    the way it is now, the silliness of our ER and EMS system is crushing the subspecialists where a small copay for everything would do away with abuse. even though there is a 'copay' for using the ER, even with government supplied insurance, it is often not collected and, therefore, there is no incentive to buy insurance nor is there any disincentive to call 911 because you can't get a ride to the ER.

    symptomatic cholelithiasis is a classic example of this silliness. if you have gallstones and have pain from your stones (biliary colick) you have declared yourself as someone who needs their gall-bladder removed.

    twenty years ago you would have had it removed at a teaching hospital or charity hospital in a reasonable amount of time.

    now you come in ten, twenty times for the same thing, get referred to a surgeon who, since the condition is not an 'emergency' (if the gall-bladder is not infected) can rightly demand payment for the procedure.

    one day you will come in with cholecystitis which IS an emergency and the poor sap on call for general surgery will be up all night taking it out for free or will cancel his paying patients for the next day in order to do it.

    right now, from a doctor's perspective, the system is all stick and no carrot. punishment for not giving away your skills and services, punishment if you do the procedure and have a bad outcome (even though you did it for free), and the best that can happen is that you see the patient once or twice in follow up and cut them loose till their next emergency when someone else will lose money and time putting themselves at risk to do a procedure that should have been done months, if not years ago.

    where is the stick for the patients? there isn't one. there's no penalty for abusing the system. it costs them nothing and they might just get lucky and be able to sue their benefactors.

    the one thing missing in the debate is patient responsibility. no one talks about it. the dirty little secret is that academicians feel that the general public is too stupid to take care of themselves. if there's no penalty for not taking care of yourself than why would you? free care? sign me up.

  31. Do wonder about why violence is needed in a socialist health system. No violence seen over here in a very well functioning socialist health system in Sweden.

  32. dear Swedoz,

    thanks for the comment. having travelled in scandinavia first let me say i'm jealous. i was walking on a hill overlooking Oslo harbor and saw a beautiful blond, topless, sunning on a towel. curious i moved closer. too bad it was a dude. oh well.

    your question seems an honest one so i have some answers and questions for you.

    our system is ten years past the point at which most of our urban and even suburban ERs look more like war-zone casualty centers than something in a nice, shiny hospital.

    we routinely take knives and guns off patients and if gang violence has taken place the police come in force as there are sure to be some gang bangers who show up in the ER looking for the 'sumdood' who capped their home slice.

    but getting to the point, the ER IS the only place for millions of people to get care here because MILLIONS are in the country illegally. millions have also chosen to drop insurance coverage because they can 'always go to the ER'.

    yes, there are many people who can neither afford a primary physician OR get insurance but i blame this on the separation of medicine from market forces and a huge unfunded mandate called EMTALA.

    correct me if i'm wrong, but Swededn is very homogenous, your physicians probably speak every language they are likely to encounter in their ER, and since you have relatively closed borders and a relatively stable population of hardy nordic lumberjacks and busty blonds (there aren't any ugly Swedes are there? fat?) your system is not subject to the great pressures that ours is.

    in fact, having taken french in high school (really bad choice and they smell) i did not know that the onus would be on me, after medical school, to learn spanish. but it is.

    it has, literally, come to the point where enough non-payors waltz into our ERs who are truly sick that the sub-specialists on call, by law and with the full force of law, are required to take care of them even though they will lose money and sleep on them, have to cancel appointments with paying patients, AND still be subject to our ridiculous tort system if they cut or tie the wrong vessel or nerve during an emergency cholecystectomy or femoral nail.

    this is the point at which violence DOES enter into the equation. in other words, 'doc, operate on this chain-smoking, non-compliant, obese diabetic who smokes or we will fine you and your hospital $50,000 and get you fired, and don't screw up or you will get sued.'

    now, admittedly, that is not a gun-to-the-head form of violence, but it is coercion... the kind of coercion usually reserved for military recruits or prisoners.


  33. I'm a Swedish med student, and I think I might be able to answer some of your questions 911DOC.

    While we do not have a large amount of illegal border crossers from Norway and Finland (if any), we do have a very heterogenous population, due to Sweden having accepted a large amount of immigrants and refugees over the years, from countries like Turkey, Greece, Iran, Iraq, Poland, Estonia, Lithuania, Finland, Pakistan, Afghanistan, Somalia, Serbia etc. Sweden is one of the countries that has accepted the most refugees from Iraq during the current war. As you might understand, Swedish doctors do not speak all these langugages, if any. We still believe that anyone should be offered health care, and we do supply it. And interpreters as well when it's necessary.

    Medical lawsuits are unheard of in Sweden. There is a central government agency that handles complaints or grievances with the health care system. They investigate these complaints and punish when necessary (doctors are typically punished with a written warning, in extreme cases they may lose their job or license to practice).

    The "coercion aspect" I guess is that if you work at a hospital, you will need to treat patients, regardless of affliction, compliance, personality, skin color, religion etc. If I didn't want to treat patients, I'd seek some other job, so I don't really see how that'd be coercion.

    You are, as a physician, allowed to start a private practice, which would let you treat whoever you want and not treat whoever you want, but you'd have few visitors when you would have to charge patients 100s or 1000s of times the fees they pay in the public health system.

    There are no health insurances, everyone is always insured at the public health care institutions. Some insurance companies offer health insurance that would come in handy if you'd like to visit private hospitals. They are not very popular at the moment.

    The biggest problem with the Swedish health care system is the waiting times. Since we all share the health care, not everyone can get fixed right away. Non-emergent conditions have waiting times of various length for treatment, some of which are unacceptable. In general though, most patients get the care they need, when they need it.

  34. dear swemed,
    thank you for that helpful information. i don't know the statistic verbatim but i believe that the United States has more than %50 of the world's attorneys. i don't mind the tort system (malpractice lawsuits) so much, but the awards for 'pain and suffering' are, at times, so enormous, that many malpractice carriers will settle cases rather than risk the verdict of 'twelve people picked off the street'.

    just how important this is has recently been demonstrated in texas where, as recently as five years ago emergency physicians could make twice what they make in most other states. then they passed a tort reform bill capping damages for 'pain and suffering' (punitive damages). now Texas is awash in physicians and folks over here are perplexed.

    quite simple, even if i have to take a pay cut (which would now be the case if i moved to texas) it is very tempting as working every shift with a legal hammer over your head adds considerably to the stress of an already stressful job.

    good luck in your studies.