Wednesday, July 22, 2009

The Horse's Mouth

There is quite an echo-chamber in academic medicine. Witness the following...

Within the past few weeks I have been able to speak with chairs of various academic medicine departments. I have done this under the cover story of "I am working on an article" (true), or "I am working on a book and would like your input" (sorta true). The responses I have received are repetitive, infantile, and quite scary.

The number one reason that academicians WANT universal health care is to put some teeth behind RATIONING. They all believe that extraordinary care at the extremes of life will collapse the system. For instance, one particular academician I talked to wants to do away with dialysis for folks with certain criteria (having to do with her ideas about of 'quality of life'). These criteria will be decided by committees (because all the best things in life have come from committees), so no one person will be to blame.

Now this is quite amazing to me. First of all, academics have sat on their hands (and cheered) while regulations have tied private corporations' hands to the extent that their ability to perform procedures such as dialysis is severely limited. The mounds of paperwork required to open a clinic were scary enough to keep me from doing it (more power to you 'Cat).

Also, academic physicians all have a a little help with their workload and it comes with the names tenure, medical students, interns, and residents. This is a kind way of saying they have no freaking clue about private practice, they believe it is beneath them, most have never worked outside the academy (because once you do it's hard to get back in the club), and yet they want to make policy that forbids or severely limits private practice. How do you like your power Doctor? Absolutely? I thought as much. Pussies. Sell-outs. Turncoats.

I am sick of the AMA and ACEP.

sent out a blitheringly idiotic email today asking us to 'pass it on' so that emergency physicians can be helped by the big pile of money building in Washington. Screw you ACEP. Screw you AMA. Count me out.

Also, the academics have been behind the self-flagellatory demonization of drug companies. I understand that junkets to the Caribbean for docs may be a bad idea, but now the drug companies are prohibited, in large degree, from giving out drug samples and even from giving out pens.

As it turns out I am particularly susceptible to the free pens. If I get one that says "Rocephin" on it that's all I will prescribe. Even for erectile dysfunction. Until the pen peters-out.

"Hey doc, my weenie don't work... ain't this Rocephin stuff for infection?"

"Sir, you know your medicine! But look at this cool pen I got!"

The academics want the government to be the bad guy behind letting granny die from her chronic illness which is all I need to confirm my suspicion that they are COWARDS of the worst variety.


  1. All I can say is "THANK YOU"!!! I opted out of the AMA years ago when they agreed that a fetus is not worthy of support, care or protection, and now I am SO glad that I did.
    The profession is dying in front of us and no one seems to care. I'm just glad that I'm on the down side of my time in the valley of tears.

  2. Psst don't tell anyone but I think Obama's got Lung Cancer... Notice that little change in the timbre of his voice? That twitch in his left eyebrow???
    Like I said, don't tell anyone,


  3. I do miss the pens. I once got one that lights up. It was pretty cool.

    You and I know we can't go on this way. It sucks for everybody. That is why I quit. I can't do that much data entry. I just can't. I do have hope that some day this will turn around and get better. I have this hope because if feels better than complete deprsssion.

  4. Stalwart Hospitalist10:27 PM, July 23, 2009

    Should, then, thousands and thousands of individual inpatient physicians take it upon themselves, in case after ridiculous case of 7th-line chemotherapy for metastatic colon cancer or CPR in a patient approaching her 6th year of nonverbal status from dementia, to explain and convince family members and caretakers as to the futility of some care that we collectively currently provide?

    This is what we have now, and the path of least resistance is (often enough) to proceed with the care in question.

    I'll be honest -- since these patients are not spending their own or their family's money on this care, but rather everyone's collective current and future assets to be claimed by federal taxes for Medicare, it may not be unreasonable at all for the people paying the bill (all of us) to attempt to set some limits at the extremes.

    The choice is often not between "letting granny die" and returning granny to weekly canasta games and personal independence; it is often between the former situation and restoring just enough health to granny to allow her to exist -- however temporarily -- outside the highly controlled and monitored environment of an acute care hospital.

    This isn't about Soylent Green. This is about what society should be asked or expected to provide for its members. At least the older generation gets to vote. My 2-year old son, destined to grow up in a world of inflated dollars and excruciating tax burdens due to the decisions already made in years past, has no such input.

  5. dear stalwart hospitalist,

    first of all, i sympathize with your position though i disagree. but here's why and it is simply this. decisions about life and death have to remain with the individual. the solution is not obvious and i don't have it, but it would be along the lines of requiring everyone to be educated on and sign advance directives. but everyone also has to pay SOMETHING for their care. otherwise we have a no win and the abuse that is now rampant.

    but the moment you take this liberty away from the individual is the day that we step ever closer to a 'logan's run' society and it is definitely a slippery slope. having worked in the VA and the military system i have seen the large government bureaucracy in action and not only is it slow and redundant, it is also HEARTLESS.

    also, tough cases, such as you present, make bad law. an axiom of first year law school. because of your work, lack perspective (as do I), and it is not my job, nor do i want it to be, to make these decisions. they must remain with the family and with the individual however unreasonable their responses seem to us. this is the land of personal choice and liberty, for good and bad.

    but your financial argument is more persuasive, and since i haven't seen you on the blog before i must tell you that the minute that medicine and the costs of it were shuffled from the individual to 'society' is the minute that we started down this stupid and sometimes cruel path.

    EMTALA is unconstitutional and should be rescinded. every single individual has to be made to feel some kind of responsibility for their care. your are correct... as it stands now there are tens of thousands of people in each state that know their care is 'gratis' and after a while it becomes easy to just 'go to the ER'.

    and the amount of free care i personally delivered to patients only in residency who were in the country illegally boggled my mind. but that's another issue.

    thanks for your comment.

  6. " it may not be unreasonable at all for the people paying the bill (all of us) to attempt to set some limits at the extremes."

    I think your line of reasoning is a trick and we're going to end up with all sorts of rationing. In full disclosure, I'll tell that that I'm an ill person with expensive meds to lose.

    "The Royal College of Obstetricians and Gynaecologists (RCOG) says the huge efforts to save babies born under 25 weeks are hampering the treatment of other infants with a better chance of survival and a healthy life."

    Are we going to ration care for premature infants but still pay for IVF? NHS does.

    "Health trusts in North Staffordshire have the toughest restrictions. Patients must have a body mass index below 30 and have not smoked for three months to qualify for any routine operation."

    Read more:

    “We oncologists agree that this drug represents a tremendous breakthrough after decades of research in the treatment for kidney cancer and needs to be made available for our patients,” states Dr. Knox on behalf of leading experts from across the country.

    Despite this, the CDR has recommended government drug plans (outside of Quebec) not cover NEXAVAR."

    It might not be unreasonable for us to believe that when the political party we don't like is controlling Congress that the rationing might happen in a way that we repulsive. Perhaps the followers of homeopathy and naturopathy have more votes than parents of preemies.


  7. LOL! I remember my dad had ashtrays from pharmaceutical companies. Bet they don't do that any more.

  8. Whoa. I just chanced on the whole government medicine debacle. Coming from Britain, I've never known any other sort of medicine, and all we have here is Michael Moore's 'Sicko' telling us that HMOs rule the American medical system, and that some government control might not be a bad thing (warning! Stupid foreigner POV!).

    Then again Britain's NHS has good points going for it, but many many bad points too. More power to you! Stupid foreigner, out.

  9. hey angry medic,
    long time. michael moore is loved by America's looney left and then, apparently, by all of europe. i'd like to punch him in the face.

    was thinking more about stalwart hospitalist's comments. fifteen years ago doctor's did a very poor job with end of life stuff. we did everything because we wanted to, and the heme-onc guys were the worst.

    however, at least at the 12 places i've worked back into residency, we allow people to die now. we 'get' the concept of 'futile care' for the most part.

    i think the concept of 'futile care' is a way out of this conundrum and that educating people on 'futile care' can be done a lot better than we do it now. but the decisions need to be left with the family and patient.

    and angry medic, the dirty little secret about health care in the US is that we are in trouble not because people do not get care, but because ANYONE can get the best care available up to and including major surgery for ANYTHING with or without money. now this is, i guess, ideal, however, the folks that 'eat' that money are the doctors, nurses, and taxpayers.

    getting some personal responsibility back into the game will be unpopular, but IS the answer. only then will our ERs decompress a bit from the 'just go to the ER' answer, which, was the truth when it was uttered by GWB, but has placed the burden of financing the best care in the world for everybody on me and stalwart hospitalist and everyone who gets consulted from the ER.

  10. Stalwart Hospitalist7:55 PM, July 24, 2009

    911DOC --

    I cite tough cases not to suggest any statutory law that ought to exist, but merely to point out that there are cases of extremely futile care, seen routinely, wherein "society" (for lack of a better collective noun) would likely agree that the value for the care provided is not there.

    I suspect we agree on more than we disagree. I agree that families and patients should be responsible, at least in some small part, for the care provided. And you obviously agree with me that when the person electing to receive the care also elects to have other persons provide the financing, then we end up in the unsustainable situation we have now.

    I'm not an ED doc, but I also agree with you that EMTALA, however originally well-meant, has morphed into an incredibly overburdensome unfunded mandate on EDs and hospitals.

    Where we probably disagree most is in the concept of a slipper slope: I remember learning (with some surprise, admittedly) in Logic 101 in college that the concept of a slippery slope is actually a logical fallacy. We don't have to end up at Logan's Run, and the idea that our ever saying "no" must result in a future in which we allow everyone who is not a productive taxpaying citizen to die, is probably overstating things.

    Anonymous --

    We ration now, except we do it by means and intelligence (it is challenging to navigate the medical system, and those who have difficulty do not do as well medically). What we don't ration we bill to our grandchildren via China.

    I don't want the status quo, but I don't think we need to be quite as stringent as the NHS either. I'm perfectly happy if we as a society elect to spend more GDP on medical care. It just can't be ever increasing in an unsustainable way.

  11. dear SH,
    i agree that if we were to sit over coffee or a beer that we would probably come to a point of agreement.

    i will not dispute that logic 101 teaches that a 'slippery slope' is a logical fallacy, but simply look at what the NHS has done with it's decreasing ability to do what in our country would be routine breast cancer chemo, routine, cardiac interventions, etc... call it what you want, but once a governmental or pseudo-governmental body has power over life or death they will grab more and more until 1. a huge black market for medicine will spring up or 2. a two tiered system will spring up, essentially what we have now but the folks with the government insurance will have their care rationed.

    come on back and let's talk some more.

  12. Stalwart Hospitalist8:49 PM, July 24, 2009

    At the risk of inviting the wrath suggested in the initial post, I will admit to being an academic hospitalist. (Separate issue: whether residents, in this new area of work hour restrictions, take away from my work, or actually add to it. I regularly clock 75 to 80 hours a week on service, right there with the allowed maximum for housestaff.)

    I would counter your example of the NHS and the degree to which they restrict care by saying that we as Americans are not, nor are we likely to ever be, as willing to have such restrictions placed upon us. If our government did not worry about the opinion of the American people, they would never have allowed Medicare to build up a tens-of-trillions-of-dollars unfunded future liabilty.

    It's only a "black market" if it is illegal. I do not think we will ever approach the Canadian setup of disallowing ANY care outside the government system. Right now it's called "retainer" on "concierge" medicine, and its pros and cons deserve a separate hearing (there are certainly both).

    We have a two-tiered health care system now. Having experienced the care restrictions I currently have with my Medi-Cal (California Medicaid) inpatients, especially with regard to formulary restrictions and whether certain outpatient clinics will see them in follow up, I can say that rationing is here now.

    I agree with DrRich that we currently tend to covertly ration care, and that we are not honest about how it is done.

    I don't want to play God with people's health care either. I would settle with having the hurdles for reimbursement and requirements for documentation ratcheted back so that I would have more time on the wards to discuss prognosis, options, and quality of life on the patient's terms, and less time making certain that my intern reviewed at least 10 systems on the history and physical.

    I'm a fairly raging moderate, neither in the anti-FREE=MORE camp (TM) of The Happy Hospitalist nor in league with the single-payor advocates. I just see us doing some unreasonable things with dollars not yet earned.

    Since we've wandered into logic theory (fun!), I will state the following in closing: this boils down to an argument of actuality versus potentiality. In the current approach, we WILL go broke. With a new approach, we MIGHT end up making bad decisions about over rationing and restriction of care.

    I hope the debate never ends. The idea that this could be settled for all time is, I think, more dangerous than the reluctance to debate at all.

  13. no wrath. thanks for being honest. this will part 1

    generate some good questions.

    i would love to believe that Americans will not fall for the NHS excesses but there's very little one can do after a law is enshrined. witness EMATALA, as far as i know the most we've ever done is say, 'wow, this sucks'. and it did not take long for the general public to figure out what it meant. it meant that a certain portion of the population was actually better served by dropping their insurance coverage.

    i would disagree with your medicare/medicaid example too... looking back at the genesis of the program the funding was initially set up for an extremely small group of people but now, between those programs and social security and disability the funding is about to bankrupt either our economy or the programs they support.

    and i disagree about never going to the Canadian extent. obama stuttered and stumbled over a question from a liberal blogger which asked, 'sir, is it true that under your bill people would be forbidden to establish new insurance policies' and his answer was, 'i'm not familiar with that provision of the bill'.

    in fact, if the 'new system' is to work at all people MUST be discouraged from going outside the system because otherwise the inequities between rich and poor will be hugely exacerbated and i don't think anyone wants that, especially not obama.

    you are correct about concierge practices. i suspect that they will be outlawed. just my opinion but again, if they are not, then private hospitals will once again spring to the fore with care that others can't get and that will keep the libs out of power for a century.

  14. part 2

    as to formulary or non formulary meds if we would simply untie 'big pharma's' evil hands this would largely go away but they are the demon of the last decade as i tried to make light of in the original piece. can't believe that my training program was so nasty to all the drug reps, they were bringing all us poor residents FOOD for god's sake. and the notion that all of us college and med school grads would somehow be poisoned by the drug reps to prescribe improperly is INSANE and stupid.

    we do, in fact, have a two tiered system now and i have no problem with writing THAT into law with catastrophic coverage for everyone and private options.

    'rationing' IS here now, but not in the sense that i am scared of. emergent care is not rationed. primary care is by more of a market economy. look at the dentists for god's sake.

    and biliary colick. come in to the ER thirty times until your gall bladder is infected because surgeons are not under EMTALA for elective procedures and i'm on THEIR SIDE. otherwise this is merely stealing and the only reason it goes on to the extent it does in our current system is that everyone thinks we are 'rich' and therefore PLUNDERABLE.

    also, our academic 'leaders' have taken it upon themselves to advocate for patients and not their physicians which is the height of stupidity. the ABA does not go to washington to lobby for their clients, they lobby for themselves which is the essence of capitalism and capitalism, as terrible as it seems withing the walls of the academy, is the most efficient way to distribute resources. end of story. every middleman or committee put in between the consumer and the deliverer of services takes dollars out of the equation and now we have hospitals full of parasites who do nothing but make patient care harder and are all RELIGIOUS FANATICS, though their religion is 'diversity' and 'equality' and whatever the latest fad is.

    and you touch on this with the requirements for documentation etc... being so burdensome that you do not have the time you want to have with your patients. the people with clipboards are worse than jihadists in my book... they think they are helping but they should be waterboarded (or forced to work for themselves in perpetuity).

    agree with your last except to say that we don't have to go broke at all. and my solution is to charge ten dollars per ER visit or ten dollars per ambulance ride. this would provide rationing of a sensible sort... patient directed. it would also force folks out of the ER and back to primary care physicains whom they would have to PAY, just like they do the dentists.

    thus endeth my rant.

  15. grist for the mill... i answer medical questions on a website for cash... here's one i just stumbled on...

    hy my son is18 month old and has a lesions on the left arm since february is a long whitespot starting from sholder and finishing next to index finger and his pediater told me it colud be tuberouse sclerosis i am very concerned i need the advice from a dermatologist i am from montreal the next appointement is i january 2010 i wiil get crazy tiil thant what i have to do, i passed yesterday a renal ultrasound and it was allright.
    please, please help me

  16. Stalwart Hospitalist11:33 PM, July 24, 2009

    I think the extent to which the scope of our discussion has expanded is extremely telling.

    NONE of these aspects of the system, taken alone, constitute the sole or even the major problem (if there even is one major overriding problem to be had). In a single comment thread, we've managed to bring in EMTALA, Pharma, academics, the AMA, residency training, formularies, Medicare/Medicaid, social justice, Canada, and Britain. I think we only forgot medical school debt and malpractice issues. :)

    You seem to agree that we should at least ration more sensibly -- some "skin in the game" as it were, for ambulance rides, etc. In turn, I will certainly concede your point on Medicaid/Medicare -- if the slope is not quite slippery, it is, at least, well lubricated.

    What should we do? Part of the problem is that people are trying to figure out how to get "there" from "here," since there seems to be consensus that America will not stand for a radical overhaul.

    I do not have the answer. I would hope that any reform would have some guiding principles:

    -- Generous coverage or subsidy for preventive care, immunizations, screening endorsed by the USPSTF, and things of this stripe;
    -- A deregulated market (across states) for catastrophic insurance coverage, which would bring the label "insurance" back into its correct venue, with assistance for those unable to afford the catastrophic coverage;
    -- Some progress on restriction of lawsuits for failure to diagnose: wouldn't it be nice to order only the tests you think you need rather than the ones you think you have to have on the books?
    -- An enormous, gargantuan, relentless educational drive aimed at the American populace about keeping themselves healthy. We will all have enough to do treating the trauma, the cancer, the infections (H1N1!), and the surgical emergencies that everyone gets without piling on the issues generated from drug use, alcoholism, smoking, obesity, and a sedentary lifestyle.

    The one I can't seem to come up with an idea for is the one likely to break the bank anyway -- what do we do with/for the segment of the population with chronic, expensive disease. These folks need lots of care, lots of coordination, and are high risk for multiple expensive hospitalizations. All of the data to date on medical homes and care coordination is underwhelming in terms of outcomes and cost-effectiveness. This, I think, is where society will (eventually) end up having the open debate about what the collective population is willing to pay for.

    I do miss the Pharma food. One of the big draws of internal medicine back when I was a student. We write the scripts, after all. :)

  17. Oooh! Ooooh! Oooooh! 9-11! I know whats wrong with that Canuck's Kid....
    Well actually I don't, so I'll do what Dermatologists do and describe it in Latin...
    lets see.... OK, its a clear case of "Punctatus Albus", now give me $$400...
    Kid probably needs his tonsils out, some ADD meds, and I'd give him a good wash and wax just to be complete...
    I know a shady ENT that'll split that outrageous Surgical fee... How much is $79 divided by 3??


  18. Lichen striatus? I had a cousin who had that when he was little. Could she send you a photo of the lesion so you could get a better idea?

    If so, as I recall, it wasn't something horrible, and I'm sure it would put this mother's mind at ease if there were a way to diagnose that.

  19. Ok Frank,
    I just about pissed myself with your comment. thanks for the belly laugh.

    okay SH,
    i've been asleep since your last and am now back in the ER taking care of a chronic copd patient with 'flames' coming up with his cough. i think i can fix him.

    i guess you and i simply have a different approach to problem solving in this particular instance. i'm a strong but minimal regulation with free market solving problems guy. i just don't think about how to solve the health care 'crisis' (where everyone who can pick up ap phone or walk or call a cab and get every single thing they need) TODAY DAMNIT! not saying you want to fix it without a nice long conversation about it, but OBAMA sure does. he wants to 'fix it' next week.

    skin in the game is the big thing. if we do this i think much of the stuff we can't seem to get a hold of will simply vanish because people will do what they should have been doing for twenty years, getting in with a pcp, managing chronic conditions there, and using the ER and hospital in true emergencies.

    agree with all of your suggestions except the educational drive. it wont work. i have just quit telling people to stop smoking and drinking and, in fact, though i do not tell my alcoholic patients this, i think it would be a lot more sensible to tell them, 'never stop drinking', that way, they will come in with their variceal bleed or pancreatitis and we can just admit them and plug them right into rehab. can't get 'em there otherwise.

    as to how to fund the chronic care i think if we deregulate the market that it will be solved. i do think catastrophic coverage as our 'nationalized health care' with every single citizen paying $50 into the pot every month is the simple and sensible way to go and then let folks pick their private coverage, HSA, what have you.

    i still honestly believe that $10 for an EMS ride and $10 at the ER door will cut a huge amount of wasted $ from the equation and folks will have to spend $5 at walgreens for their home pregnancy and might even figure out that giving tylenol to kids with fevers is, in fact, okay.


  20. Loved this post...might I suggest the following link to a post on a very good site that deals with Liberty from an economics perspective...

    I sincerely hope that we wake up and take our country back; if not at the polls in 2010/2012 then by other means in order to prevent the decay into National Socialism. --->even the enemy sees what's going on!

    God Bless!