Wednesday, March 11, 2009

Rambling and Gambling

Warning readers; This post has the potential to go to diatribe or polemic or simply phrase an honest question. I need your thoughts... here goes.

I noticed when I was in the military that the upper officer ranks especially in the Medical Corps were populated by clipboard people. This did translate a bit over to the combatant ranks as well and this was a mystery to me, because it is in combat that we need our unconventional thinkers, our thinkers who have actually been in combat to leaven the bread of the ideas from those who have only been out on training missions or have 'gamed' scenarios on computers. When the bullets start flying is when a George S. Patton or a Ulysses S. Grant become stars because they know what works and they do it and will not brook any disagreement. Since the result is either victory or defeat in war the bureaucracy relents in these cases and hands the power to these folks who would never have made it so high on the ladder in peace time.

Let me analogize over to the medical world. All of the National Colleges (the AMA, ACEP, ACOG, AAS, etc...) are populated mostly with academicians who work firmly ensconced within the walls of academia. I propose, therefore, the following. Within academic medicine there are a few things that you NEVER point out or say due to the deep penetration of political correctness. For instance, if I went into a faculty meeting at any Emergency Medicine Training Program in the country and pointed out that 40% (conservatively) of our patients are lying when they say they have no money, no jobs, and no insurance, I would be punished, counseled, or simply fired. After all, being 'bipartisan' is the new religion, but only if your partisanship is to the left. Partisanship on the right is called 'hate'.

I believe that a not-so-subtle prejudice reigns in academic medicine born of Darwinian thinking and a core belief in socially engineered programs up to and including economic socialism. Most academicians look at the rabble that comes into their ERs and think that there is no way these folks could ever take care of themselves, so, being the compassionate liberals that they are, they see the only solution for our health care crisis as one borne of a huge government program funded by huge government taxes..

Meanwhile, we simple community physicians who still see patients one-on-one know the above not to be the case. We see a system that is about to make a terrible choice, one which will cement the now underinsured or poor into remaining, forever, in the lowest socio-economic class. After all, if they can live a comfortable existence and have their cigarettes and cell phones and cars why would they want to risk screwing it up by getting a job or pursuing a higher degree of education. We also see that in other areas of their lives, like financing a car, buying a cell phone, or getting those Marlboros on discount, they definitely DO know what they are doing.

To quote Gayle and Evel Snopes from Raising Arizona, "Hi (Nick Cage's characther H.I. McDunough), you're young, you got your health, what do you want with a job?"

Well, we are entering a wartime situation with America's health care. The pointy headed ones who do not routinely care for the poor and underinsured (their residents and interns do the scut work and they supervise... they are also not paid based on any kind of production ratio) find it very easy to 'drop back and punt' and say 'let the government solve it... it's too big a problem'.

This explains why, at my private hospital that has to support itself without the help of huge endowments and grant money, we are upset when we have to keep patients in the ER waiting for a bed upstairs for more than 6 hours, but, at the MECCA down the road, where I tried to transfer a trauma patient last week, their wait time for a bed was 90 (yes, ninety) hours.

Academicians are much better at research than I could ever be, but why does this mean that they are more qualified to fix the system than community physicians who see the problem first hand every day? The very physicians whose livelihood depends on being efficient? I guarantee you this, in whatever super-duper government panel that is formed to solve this crisis there will not be one, NOT ONE, community physician or community ER doc. The reason is that we would disrupt the plans that they have already hatched, and it's a bitch to have someone on a committee that doesn't operate from the 'I'm not going to make waves' perspective. Screw that.

The only way to fix our system, which is still a better system in terms of delivery of the best care in the world to anyone who comes into the ER, is to put some responsibility on the patient for their care. I said SOME, not all. If they don't have to do anything to access the system, if they don't feel the pinch, then why would you expect idiotic calls to 911 like the one in the previous post to stop happening? It wont, but what will happen, is that community hospitals will mimic the academic centers in all regards, especially the 90 hour wait for a bed from the ER.

With this perspective it is easy to see that it is in leftist academia that freedom and equality are merely throw-away words. They see the poor and underinsured of incapable of doing anything for themselves and they would prefer it if it could be arranged that they never had to have any interaction with them. They are almost there. Meanwhile, I, and my colleagues on this blog, see them every day, and care for them every day. I'm not asking for praise, I'm just asking you to realize that the head of the American College of X Physicians does not. And the worst thing to tell someone that is currently falling on hard times is that they can't help it and that there's nothing they can do, but that the government will take care of them. Disaster.

Here's something that our founding fathers figured out. The best solutions are arrived at by representatives from each party to the debate VIGOROUSLY DEBATING THEIR SIDE AND ARGUING LIKE HELL TO PROTECT THEIR SIDE and when the smoke clears and a compromise is reached all are best served by THIS solution. Bipartisanship is a debate-killer and therefore does not belong in a representative Republic, and certainly not in business... that is, unless we go to a one party 'supreme leader' system. Good luck with that last one.


  1. May I offer to hold your coat and otoscope while you bravely fight this battle?? You have summed the problem up brilliantly. I am tired of being "played" by these folks, while concurrently being told I lack compassion for the poor and downtrodden. Wanna see poor...head to Port Au Prince or Darfur. The ivory tower morons have some vested agenda for wanting to "help" people who should get off their own lazy asses and help themselves. My personal addendum to EMTALA is that if you present with [a[ hair weaves [b] a cell phone [c] wearing designer clothes or accesories or [d] smoking, an automatic $50.00 fee will be charged upfront in the absence of arterial bleeding. And..the return of foundling homes instead of cash and apartments to baby-mommas. But hey...I'm just a mean ole' working person and I don't "understand"...

    Pattie, RN

  2. Bravo, sir!!!
    You said in a few paragraphs what most of us think but cannot put into words, and I thank you for it

  3. As long as docs keep payin the Boards fees and takin their exams they'll have the power... I'm lucky, with my background the Boards pay ME to stay away...Just remember, you're not the initials after your name, Your're not an USMLE score, you're the all-singin all-dancin crap of the the future I see, you'll stalk elk at the ruins of the Rockefeller Center, You'll wear the hides of animals you killed with your own hands, that will last your entire life...
    or Not... been watchin' "Fight Club" again..

  4. Brought tears to me eyes, 911.

  5. bravo.

    ask any of these mecca institutions how they deal with ED crowding: they try to shuttle patients off to either a community hospital (see: UIC/dogbite), or to a community based clinic. The problem with that is that when they do that, they just transfer the burden somewhere else, leading to the same problem. Shit flows downhill, and eventually, Podunk Hospital ED will be overflowing with patients.

    Academic institutions are as close to socialized medicine as you can get (short of the VA system). Many are county hospitals (See: MetroHealth in Cleveland, Jackson Memorial in Miami, University Hospital, Cincinnati). They HAVE to take the patients on medicare and medicaid, and whatever mundane complaints come with them. From there, you get horrific waits in triage, 90 hour waits for floor medicine....for what? Cheap ED labor from residents?

    People need to have some aspect of responsibility for their care. When people in this country will be faced with the prospect of losing emergency services because hospitals can't afford to sink their assets into money losing ED's, maybe that will get them to realize that a single episode of vomiting does not warrant a call to 911, or a day of runny nose shouldn't get a trip to the ED, and rather, they should see a PCP or *gasp* see what happens.

    Americans (and yes, I am one) are so hell bent on immediate results and a "fix this NOW" mentality that it's fucking the system for all of us.

  6. Well, as a nurse, all I see is a sick dynamic of co-dependency where all patients must have all needs met (it says it in our admission assessment)and if a patient is a jerk, we're supposed to jump thru hoops to "understand" their behaviors. Most of my co-workers wouldn't say shit if they had a mouthful of it. Draw a line in the sand....bad nurse. call somebody on their behavior...badder nurse. Gotta keep those beds filled so let's suck it up, do those med recs and not mention to drop a ton or two, throw away those smokes and get rid of that fancy phone so you might have a little income for the old health insurance. sorry fellow nurses until we grow some balls we just big old enablers.

  7. I've heard this scenario before. The proletariat hero who works "in the trenches" every day and has all the common-sense answers that the management never seems to understand. If only they would listen!

    I wonder if there is a blog out there somewhere written by some executive who is - at this moment - lamenting about how his underlings, despite all of their day-to-day hands on experience, fail to see the bigger picture. A yin to your yang?

  8. dear anonymous,
    i've heard of your scenario before too! anonymous poster looks at 'both sides' of an argument and comes down directly in the middle. if the argument were between Timothy McVeigh and John Wayne Gacy you would bravely find something to like about bothe of their positions on the issue.

    but no, i have not heard of any admin-weenie blogs. they would be far to concerned with 'liability issues' to risk their cush jobs for an ideal.

    and finally, anon, i do not claim to have 'all the answers', but i do claim that those offered by the left will do tremendous damage and not just in health care.

  9. Anger is a gift.

    Well said 911.

  10. 911,

    It is good to see that you are one of the few who have not given up. Maybe too few.

  11. 8 contributors and only 2 posts a week?? And not to be a Meanie Genie but some of em' sort of seem a little sloppy and slap-dash, like those book reports I used to write on the way to school...But it's still the best Medical Blog out there...

  12. From a Libertarian who has found herself working in Academia completely by accident - you are not wrong! However, one of the things I can offer residents is a "real world" persepective on the practice of Emergency Medicine. Having practiced in rural community hospitals, community hospitals in large cities with academic centers, and now in an acedemic center, I will say that the academic centers do not shunt patients to community hospitals. It si the other way around 99% of the time. But whether patients are shunted one direction or another, the bottom line is the same - taxpayers are ripped off, and people who pay for private insurance are completely screwed. We all seem to focus on the role of the hospital admin weenies and physician fees in regards to skyrocketing health insurance costs, but no one ever bats an eye at the fact that insurance CEOs are going home with 7-10 figure paychecks.
    But back to my point - I agree that academicians teach medicine as if the only placee to practice is in another academic facility. Perhaps more community-based docs should be involved in the education of our future docs - EM and other fields - in order to better teach the practical side of medicine?