Sunday, February 15, 2009

A Core Fallacy of Liberal Thought

I have always felt that liberal policies work well on a personal level (and many folks are surprised after getting to know me that my political beliefs are not liberal), but liberal policies produce disaster when enforced on a governmental level. To wit, many folks with really expensive degrees from really expensive universities have the idea that our health care system is flawed because of lack of access to care. I disagree. Our health system is flawed because there is no way to make a perfect system, AND when the system is aimed at the lowest common denominator there will be incredible waste which hampers our ability to care for more folks in the best way possible.

"AMA" means 'against medical advice'. There's an eponymous bestseller out there right now as a matter of fact, but in the ER "AMA" means a patient is choosing to leave against my advice. This is not a rare occurrence. It is a daily occurrence.

I took care of a guy tonight who came to me, asking me to figure out why he was 'muddle headed' (as he put it) and 'dizzy'. Of course he was uninsured, and of course he smoked. I didn't make much of his initial complaint but ordered the right tests and voila! I got a diagnosis. He was as surprised as I was at his diagnosis of a brain tumor, but left AMA.

The reasons are not important in this particular case, but the stupidity is. No he was not so altered as to impair his ability to make this decision for himself... He gave, as it turns out, a rational reason for leaving albeit a silly one. I told him that he should stay and get this worked up and that it could mean the difference between life and death, his busy schedule would not allow it however, and this, along with the fact that he can come here anytime 'for free' makes the $5000 we spent on him today none of his concern. And YES, I 'got on his level', 'walked a mile in his shoes', translated doctor speak to regular-speak, expressed concern, and really formed a connection with him.

So the liberal sentiment here would be to do everything possible for this guy regardless of his decision to drop his insurance, his smoking, and his decades of poor decisions. We did that. What to do when even this is refused? When the bite of poor decisions is made painless then how exactly do we get the populous as a whole to make better decisions regarding health care? Education? Right.


  1. What disturbs my calm is the willingness of the government to give a blank credit card of health care to those with no concept of how to use it appropriately. You "lucked out" in the sense that you actually found something wrong with such a patient. Usually it is the opposite. We have all treated the emergency mosquito bites, sunburns and "weakness for a year". all coming in by federally funded ambulance. Our Federal government is happy to pony up the 10 cents on the dollar. But ask the government to actually go out and police their realm is like asking a babydaddy to pay child support without a DNA test... it just can't be done.
    Meanwhile, some average Joe is sitting out there chewing Tums hoping the excruciating indigestion causing him to sweat will go away, because he has a $5000 deductible catastrophic policy.
    What is the proposed government answer to Joe? Why put him on the mosquito bite plan and blame the "overpaid" doctor and hospital when he dies in the waiting room because the ER is overwhelmed by crush of people demanding free care. It will be more noble to die in an understaffed, underpaid ER waiting for care than at home not affording care.

    BTW... are AMA's viewed in your ER by administration as the administrative equivalent of a "never" event? Administrations here use them as an ER group contract "sever event"

  2. igloodoc,

    i am too stubborn and too old school to listen to hospital administrators when they start talking about 'never' events and 'sentinel events' because to me it's all masturbatory job-protecion designed, not to get at the problem, but to put something on paper that looks important.

    this is why i will likely always be a locums guy from here out. i can't alter my practice to make things appear peachy for some regular sleeper with a boss in some other city who has never practiced clinical medicine.

    i get what you are saying about a 'sever event' however and that's another reason i like the locums route. locums may just save medicine in america because it allows for our unique skills to be put up for bid in a market of sorts, and if i don't like the place i'm working there's another hiring (a lot in fact).

    it is a saving grace of EM that we are not easily replaced, and at the fifth or sixth permuatation we get back to market forces.

    my goal for the next couple of years is to pay off everything i owe so when the left takes what's left of a market out of medicine i can kiss it all goodbye and watch the crash. i will take no joy in it, but i do not have to be in it.

    and for all you haters i must point out that while i do consider myself to be of high worth in the realm of medicine it's about all i can do, and i long ago surrendered any conceit and pride regarding same (other than what you read here).

  3. 911doc, exactly do we get the populous as a whole to make better decisions regarding health care? Education? Right.

    I hope you're not counting on the public school system to indoctrinate students regarding responsible health matters. Those schools have a vested interest in teaching that responsibility for personal health care is ultimately the responsibility of government at all alevels. To add insult, funding for such "teaching" is the usual suspect, the taxpayer.

    To those smart physicians who want to escape working in the current medical care system, remember that y'all are going to be the patients of the current crop of students, as your own lives (and families' lives) drift toward the end. Staying in the fight NOW seems like the only solution.

  4. The guy was doin Society a favor 9-11...Unless there's some cost effective cure for Brain Tumors you're keepin secret...How much of that $5,000 was for the CT/Radiologist fee? I'd have thrown in an LP too, just for S**** and Giggles...When I get slapped with the Glioblastoma stick hope I'm as realistic...


  5. I agree with Frank that perhaps given this particular patients diagnosis, that it may not matter what he does. But what really grates me is when pts leave from the ED AMA, then we get an urgent consult to cardiology to see the idiot who left AMA the day before. Sorry, but we don't treat unstable angina as an outpatient.

  6. What happened to your other site? Did the lawyers get ya?

  7. amy,
    i wondered about that too as i just put a new post up there and when i first pulled up the site i saw nothing. please let me know if you can't read the cases... there are three cases up there now.

  8. The cases on the new site are readable! The Marafan one is great.. I know a person with this!

  9. I'm a bit confused by this. Maybe I read it different than they way you mean it as you were writing it.

    What is wrong with him checking out AMA, not considering that he may never pay on his $5,000 bill for the work-up? Isn't that like taking a car to a mechanic for "a knocking sound" and finding out what the problem is, then taking the car home to fix it later or let it rust to the ground? Why does he have to be treated? Could it be that he only wanted to know what he was facing medically?

    Forgive the 5 a.m. questioning, but I really don't understand why it is so bad that he went AMA.

  10. Anonymous 4:38 was me - Stiff Man.

  11. Well, I think that question is actually quite simple to answer. This is a human, not a car. And no matter how calloused and disheartened a physician may become most still remember that they went into the profession to help people, not simply to make money(that doesn't mean they don't care about money).

    Granted, I'm not a physician but 911Doc admitted to being a bleeding heart(more or less) on a personal level so this would be the best reason why 911 would actually give a damn. Let me add, I think it's great when professionals still care about people instead of just making a buck and going through the "nine to five" drudge like many in business do.

  12. anonymous,
    that's a good question and i hadn't looked at it from that perspective. it is true in this case that this tumor is unlikely to change dramatically in the next week or month, but from my perspective here's the problem. he knows now that he has a brain tumor. he's the kind of patient that will not follow up as i arranged with the neurosurgeon. therefore, because he's 'self pay' the rules of EMTALA don't apply and he will have to either pony up $$ for the neurosurgeon (unlikely) or get insurance (fraud unless he tells them about the brain tumor) or wait for the next time he feels sufficiently bad to come to the ER where we will repeat his CT scan and offer him admission. wasteful to the extreme. if he had come into the hospital under EMTALA each doctor engaged in his care would have had to scrape and beg with the state for some form of recompense but he would have been definitively diagnosed and treated. as it stands he has just put himself behind two eight balls and IS at risk for sudden death should the cancer erode into a high pressure vessel (unlikely but possible).

    i guess i just never cease to be amazed at people who are scared enough to call an ambulance, come to me fearful of bad news (which was delivered) and then get up and walk out. cognitive dissonance.

  13. I work in EMS, so we're on the scoop side of your litter box. It's precisely this Access To Care that is the problem. It's TOO MUCH access to care. We give these fucking idiots way too much leeway in their care. Their stupidity is what fucked up their lives, so I'm not too inclined to give them preference on dictating care. But that's not what the law says.