Wednesday, October 20, 2010

Lest You Wonder About Incentive...

Ah, government work. I like it! Yawn. I'm getting to be a downright near-perfect paper doctor. I've got training requirements, administrative time, all federal holidays off, and blocked appointments,  and yet one thing remains the same as in the ER. The time I spend with each patient is minimal. It's more now, of course, than in the ER, but it is minimal nonetheless.

The way our system is set up I have to type the patient encounter into the low-bid EMR, and, with some service-members I have to write it down on paper too, and then enter it into a separate database by computer. So, for a thirty minute appointment, I typically spend 5 minutes with the patient and 25 with the computer. And since I get paid the same no matter what it is relatively easy to understand why so much hinges on what form our health care system will take... on whether physicians will retain some monetary incentive for working harder or smarter. If not they may all turn into me! I leave the building at 4pm sharp each day and the phones roll-over to phone-tree hell at exactly the same moment.

And this EMR thing... Oh my goodness, I agree that it is nice to see previous encounters on patients in real time and to have labs and rads at my fingertips, but the amount of garbage information in each encounter is, I would guess, around 90%. Any EMR not designed by and for providers will be a dismal failure, just like the one I use now.

55 comments:

  1. Working in a system where all doctors are paid the same regardless of specialty, what incentivises is called self pride. You work hard because your patients need you and you work as a team. You are taught from an early age that to gain respect you have to be good at what you do.

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  2. Its like when I had a paper route in 1976, and every new customer was worth $1/month profit...
    Turf Wars with the rival paperboy that make Bloods/Crips look like Perez Hilton/Miss South Carolina/ Schemes to defraud the LA Times Bernie Madoff would be proud of...
    Y'see, if I didn't tell the paper about a few new subscribers, and instead, stole, I mean appropriated the papers from the paper machine, your profit went up like %800...
    Of course when I moved across the country, the new paperboy had like 17 irate customers wondering where there paper was....
    MWAHAHAHAHAHAHAHAHAHAHAHAHAHAH

    P.S. The Statue of Limitations ran out 20 years ago...

    Frank

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  3. (...pictures statue with Snidely Whiplash mustache, running off the screen).

    That's right, kids, there used to be a thing called newspapers and cartoons were only on TV on Saturday mornings.

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  4. Best Part was you got the Sunday Papers delivered on Saturday Afternoon, pretty cool bein able to read "Parade" magazine and Mary Worth before the common folk...
    Worst part was delivering 70 5lb Sunday LA Times the next morning in the rain...

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  5. Grumpy RN,
    Your idealistic premise is the basis of Mao, Stalin, Castro and Chavez' collective failure.

    Human nature has proven you wrong throughout the ages. Take away financial incentive and man will be reduced to the lowest common denominator.

    Those on the bottom of the food chain seem to generally resent those higher up....I submit you would have a problem with nurse assistants, LVNs and RNs all being paid the same. Why are BSN RNs higher paid than non degree RNs? Nurse Practitioners might think they are better than the MDs they pretend to be, but we know better don't we? etc.

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  6. dear black ink... can't believe it took two days for a response such as yours. i'm just glad DRX is on vacation or he would have dispatched some of his former GRU cronies to instruct our 'grumpy rn'. many thanks.

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  7. and dear BLACK INK,
    love your avatar. if you earned it, i bow humbly to your awesomeness.

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  8. Da! I mean 'yes', the Special Warfare device. Very impressive. And it is true that it is best that BLACK INK got in first, but I must add this, in the old country they would pretend to pay the people, and they would pretend to work. I suggest the same be tried here as many of my friends would benefit.

    DRX, Southern Hemisphere for now

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  9. Blackie got it, yes, but Frank nailed it, first.

    You're getting sluggish, 9.

    When I was a kid, I delivered papers WITH pride, up before 5 am folding and delivering them on my way to school, before anybody else in the house was even awake. But I did it FOR a whopping $150 a month, a fortune for an 11 year old. Every morning, even a rainy one, was beautiful morning and a great big FU to the slackers in my house, and neighborhood.

    BTW, one of my neighborhood slackers, also my age, woke up much later and was driven in to his private school many miles away, because Pounahou was nowhere near Aina Haina, where we lived. So, although Obama wrote of the terrific challenge of growing up with a single mom, accepting food stamps, I was growing up blocks away while my Dad was in Vietnam, cranking my bannana-seat up and down the same dark hills in which he lived, loaded down with copies of the Honolulu Advertiser. I went to Aina Haina Elementary and my brothers and sister went to Niu Valley Junior High, or Kalani High. Obama was driven far away to Pounahou. I am a few months older than him so that means that when the sun came up and I started getting close to school, he was probably almost through with his car ride to Pounahou, on the same days. I don't know where he was getting his money for weed, but he sure wasn't working for it. Obama was a ghost, in my neighborhood. Never saw him, never met him. That's saying something for somebody that delivered papers to nearly every home in the entire neighborhood, collected for papers at the front door of those homes, played in the school yards, climbed the rocks, surfed the beaches, he just wasn't there. That guy did not exist in my neighborhood, where he presumably was raised, after returning from Indonesia. I looked up his address from that time period and it is right there where the rest of us lived and played. And I worked, early in the morning, because I was lucky enough to inherit the paper route from an older brother.

    Some people have an abundance of pride and have never earned a living. Other people would never accept food stamps, not out of pure pride, but because they know that is there for people that might really need it and they could find a way to work harder.

    Pride doesn't pay bills. Pride drives someone to find a way to pay bills. That is the fundamental truth that escapes socialists.

    Yeah, we all noticed that first comment, 9, but we ignored it as the nonsense that it was, after Frank skewered it, with his profit-motive story. Better to laugh than pile on.

    Not that there is anything wrong with a good pile-on, as long as everybody is naked!

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  10. so that's what frank was on about? i just figured he was doing a free form jazz deal after another auburn win and hadn't burned off the tequila and peyote buttons yet.

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  11. Mao, Castro, Stalin, Chavez....? What are you talking about? I did not mention any of this.
    Is this the usual American nonsense of being unable to understand the difference between Socialism and Communism?

    I merely pointed out that some people can be motivated by the pride they take in their work. As opposed to the system where you take pride in your bank balance.

    "Nurse Practitioners might think they are better than the MDs they pretend to be, but we know better don't we? etc."
    So you have looked at my blog, do you actually understand anything at all about my job? I do not pretend to be an MD, I have never said anything remotely to that effect.

    Interesting that an American would threaten me with the GRU while referencing communism. Do you really not understand irony?

    Sigh......, I tried to show differences from another country, get some discussion about incentives and making a different system work. I should know better! All I have received are abuse, threats and general stupidity. Thank you for this, it is nice to have it confirmed that most Americans seem to be oxygen thieves and are probably too stupid to live.

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  12. no doubt many are motivated by pride in their work, but would they do it for free? no. so there is an element of incentive, and for many, perhaps sadly, a large bit of it, that comes from money, being able to provide for family etc... and you must forgive DRX, he is a bit confused about his loyalties these days. i congratulate you, grumpyRN, on not letting how much you are paid affect your work in any way. as you Brits would say, 'bully for you'. oh, and i know full well the difference between socialism and communism, and it the difference in the level of the common misery and hopelessness... you know, whether you get an occasional taste of bombay gin versus a steady diet of victory gin. cheerio and keep on keeping that NHS at a certain level of something!

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  13. Give me an army of those motivated only by pride in their work and I will build you a Zil limousine... just one though.

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  14. "no doubt many are motivated by pride in their work, but would they do it for free? no. so there is an element of incentive, and for many, perhaps sadly, a large bit of it, that comes from money, being able to provide for family etc... "

    Now that response should have been the first one, it is reasoned, measured and leaves room for reply/debate. And you are correct, how much I am paid does not affect my work. I give a fair days work for a fair days pay, as I agreed when I took the job - can
    American doctors say the same? Or, will they charge all the traffic can bear?
    No one works for free and I did not say that or infer it. In your post you were wondering if doctors who are paid the same regardless of what they do will just coast? Well it appears that under your system then yes they would. However, it does not work that way when you are trained in a system with a bit more altruism in it.

    The NHS is fine thank you and because of it we in the UK have a longer life expectency than US citizens.

    DXR;
    Zil? Did you not pay attention in 1989? Or perhaps, unlike 911, you really do not understand the difference between socialism and communism.

    That's it for now. So as you said 'cheerio' and I now await a response from Black Ink and CJrun.

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  15. pip-pip cheerio! glad we are all pals again. but wait... one minute... could you please define 'fair' for me? i mean, if your pay per day ceased being 'fair' how could you then give a 'fair' effort? i hear there are a lot of government layoffs over there right now, i hope they are done 'fairly'.

    and one of your excellent ER physicians tells a bit of a different story, by the way. as does this little bit from one of our throwaway journals.

    and finally, to answer your question about American doctors, we are too altruistic, because in giving away so many of our services gratis, we have created a population who expect that their health care is someone else's responsibility.

    i make 30 cents on the dollar. is that fair? toodles.

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  16. Tick-tock... Phone calls... Web searches... Rewrites X 5... And now, ladies and gentlemen, may I present to you lameness incarnate....

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  17. "Tick-tock... Phone calls... Web searches... Rewrites X 5... "
    You do know that the UK is on a different time zone don't you? While my comment is stamped in the early afternoon it was in fact late at night and some of us lesser mortals need sleep - we also have lives to live.

    I have no idea where Dr Shroom works but I work in a university teaching hospital in a small to medium sized city and we have 24 hour cath lab. Why he does not have access is due to local decisions, not national ones.

    The article you reference means nothing, it is just political tinkering from a new government which wants to be seen to be 'doing something'. It will make no difference at all to the patients.

    Layoffs? All governed by employment law and therefore must be fair.

    "And now, ladies and gentlemen, may I present to you lameness incarnate...."
    Interesting that rather than engage in meaningful debate or discussion, throughout this whole thread I have been abused and attacked. Argumentum ad hominem perhaps? However, yet again my predjudices are confirmed.

    I will pop back here intermittently to see if anyone can actually write something intelectual and stimulating, if so I will answer but more of the same will be ignored.

    Toodle-pip for now old boy!

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  18. thank you for not disappointing.

    "Layoffs? All governed by employment law and therefore must be fair."

    and should you choose to return, the question stands, define 'fair' please, as in, what is a 'fair days work for a fair day's pay.'

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  19. I'm enjoying Grumpy's posts....is your patient care exponentially attached to your financial incentive? If you get paid x, the patient will get crap care vs if you get paid y? I'm not starry eyed..I want fair pay for a hard day's work but what makes me sleep at night is that I made a difference in some one's life that day and not how much I made that day.
    Oh well I'm the dinosaur daughter of small town GP that took bushels of corn for payment and made house calls at 3 AM without ever complaining. You can read about those docs in some dusty history books.

    And as for this:
    "and finally, to answer your question about American doctors, we are too altruistic, because in giving away so many of our services gratis, we have created a population who expect that their health care is someone else's responsibility."
    This sounds like a preacher who is shocked that he has a congregation of sinners.
    Medicine has always been a delicate balance between altruism and pay. If you're looking for "fair" it ain't happening.

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  20. dear midwest woman,
    i am so glad you are enjoying grumpyRNs posts. perhaps you can go over and follow her/his blog? in the meantime can you define her/his desire for a 'fair day's work for a fair day's pay' because i'm still waiting. and thank you for your summary of the history of medicine, medicine certainly is not 'fair', and it's becoming less and less 'fair' as we proceed down our current path. but the 'unfairness' will impact folks like you, not me, as i will always have a job, there are less and less of me you see, and our surgical programs are not filling because the profession of medicine is no longer under the control of physicians, but, rather, under the control of people who want it to be 'fair'. it will certainly not be fair in the year 2020 that you have to travel 500 miles and wait six months to get a neurosurgeon to do your brain cancer operation, but everyone will be in the same boat, so it will be 'fair'. i mean, everyone except physicians, who will have an 'in' with their colleagues and be able to get that surgery right away... physicians, and, uh, people with money. so let's go all out for this 'fairness' you speak of if you like, me, i'd prefer to provide the best care to the most, and the best way to do this is with this thing called 'capitalism', but, again, this may not seem 'fair'. off to the temple of 'fairness' to worship at the foot of the great altar of 'fairness'. driving my new chevy volt there too, had a better car, didn't think it was 'fair'.

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  21. Hey Midwest Woman, and as a chidhood resident of a Midwest Gulag, I mean small town, I still don't get why people live there...
    Siberian Winters out of a Dostoyevsky Novel, Mosquitos the size of Vampire Bats, Fewer Minorites than a Haden Lake Idaho Klan Rally...
    Oh yeah thats why, and I didn't have a choice, I was an AirForce Brat...
    And gonna call BS on the "Payin with a Bushel of Corn" crap, first of all, lets just say your "Small Town GP" only charges $50 for an Oxy Scrip, I mean, Office Visit, at the current spot market rate of $5.77/bushel you'd need 9 bushels (504 lbs BTW) and if you consider the normal "Small Town GP" has to write 40 Oxy Scrips/day I mean Office Visits/Day, he'd have an Office full of Corn by the time the Duragesic rep brings Lunch...

    Frank

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  22. Grumpy LVN,

    "From each according to his ability, to each according to his need (or needs)", is a slogan popularized by Karl Marx in his 1875,"Critique of the Gotha Program". The phrase summarizes the principles that, under a communist system, every person should contribute to society to the best of his or her ability and consume from society in proportion to his or her needs.

    In the Marxist view, such an arrangement will be made possible by the abundance of goods and services that a developed communist society will produce; the idea is that there will be enough to satisfy everyone's needs.

    Although Marx is popularly thought of as the originator of the phrase, the slogan was common to the socialist movement and was first used by Louis Blanc in 1840, in "The Organization of Work", as a revision of a quote by the utopian socialist Henri de Saint Simon.

    Marx incorrectly believed that each person would be motivated to work for the good of society out of self pride despite the absence of financial incentive compelling them to work; simply put, a "fair" reditriution of the wealth didn't cut it. Marx's idea that work would become such a pleasurable and creative activity was that all would be wonderful proved to be nonsense.

    Marx intended the initial part of his slogan, "from each according to his ability" to suggest not merely that each person should work as hard as they can, but that each person by virtue of self pride would best develop their particular talents. historical bullshit to put it kindly.

    Claiming themselves to be at a lower stage of communism ("socialism") in line with Marx's arguments, the now collapsed Soviet Union adapted the formula as: "From each according to his ability, to each according to his work (labour investment)".

    Communism, unlike the Soviet Union, is a democratic, moneyless, stateless society.....so in that vein one can understand the confusion voiced by,"Grumpy nurse because I'm not an M.D.".

    Little socialists evolve into even smaller minded communists and produce Grumpy old Brits who, ironically, fail to grasp that it is precisely their "sheep mentality" which has led to the crumbling of the once great British Empire....Bloody England, as you aptly demonstrate, has lost it's way.

    BTW, in a socialist state the fairness of one's wages is determined purely by the state......self pride and work product notwithstanding.

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  23. Grumpy RN's latest post on his blog, Thursday, 7 October 2010:

    "Do they think we are mad?
    What the hell goes on in an NHS managers mind? First they tell us that jobs in Scotland will be cut including Nursing jobs and now NHS Grampian have come up with this little scheme.
    What makes them think that nurses will work a full shift for nothing? We already work extra (unpaid) hours to make sure that everything is complete before we go off shift and I very rarely see anyone getting their time back. So now they decide to make us work another 12 hours unpaid. Never mind that this involves transport costs, childminding costs and any other costs that are involved in going to work. They then play the guilt card, "if you don't do this then nurses will lose their jobs" - you have already told us that nurses are going to lose their jobs anyway you dipshits.
    And of course, how many nurses get a break or a full lunch time? How many managers get a full lunchtime?
    I wonder though........? Perhaps this is a sneaky way to reduce the pension deficit in the NHS. It is well known that long shifts and no breaks are bad for your health so perhaps they are trying to kill us all off so they don't have to pay us a pension."

    It's funny how we see things so differently when the pebble is in our own shoe......I guess self pride instead of financial incentives only apply to M.D.'s.

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  24. dear BLACK INK,
    pardon me for a moment...

    BWaaaaaaaHAHAHha!

    game, set, match.

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  25. I think rather than argue that one system is better than the other it would better to agree that both are flawed. I'll see your NHS horror story and raise you an American travesty.
    I have a house in a Missouri county where there is one doctor for every 1200 people. There are only small towns with minimum wage jobs and small struggling farms. It's obvious no one can sustain a viable practice there.
    What's the solution..I don't know.
    Would you be interested in a government that instead of offering healthcare to everyone would instead pay for the education of physicians in return for them working in these outlying areas for a certain length of time? A "Northern Exposure" if you will? Perhaps a government that would invest money into these areas so appropriate facilities would be available for care?
    AS far as Grumpy's post, it's a legitimate beef. No pay is entirely different than an unappealing financial incentive.
    Hey, Dr. D., you know I'm an old fart..no oxys around in the 60's when my dad was doing his thing. And go Missouri Tigers..makes up for the Cards tanking in September..proof positive that Pujols isn't roided up.

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  26. PART I:
    Responsible health care reform should reward good behavior rather than corrupt politicians.
    Instead of modeling failed and/or inferior health care delivery systems in total while trashing our existing system; it would be more appropriate to identify the issues and apply a risk benefit analysis of the options.
    A basic health care reform bill should incorporate the following components:
    1. Reward healthy behavior and penalize high risk behavior.
    2. No penalties for pre-existing conditions unless they are a result of high risk behavior.
    3. Mandatory modified medical flex plans for all non-indigents.
    4. Indigent care clinics for the "under-insured".
    5. National tort reform.
    6. Common sense overhaul of the FDA.
    7. Free market insurance coverage that is portable with no carrier restrictions based on state lines.
    8. Minimize and aggressively prosecute fraud and abuse.
    9. Design a program that is open to innovation and not static.
    10. Attract the best and the brightest to enter the medical field instead of running them off.

    Health care is a business and businesses thrive under a competitive free market capitalistic system better than any other model in the history of civilization.

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  27. PART II:
    The Plan:
    All employees and any one else who wishes to participate in private American health care shall have the opportunity to purchase high deductible catastrophic health care from any carrier authorized to conduct business in the USA.
    The employer shall be responsible for at least that portion of the catastrophic policy that was adversely rated as a consequence of the employee's job duties and may pay up to the entirety to attract and retain employees.
    All coverage will be portable.
    Every employee shall be required to contribute from each paycheck to a personal Flexible Health Care Plan until said plan is funded with sufficient dollars to cover his/her/family deductible; any contributions thereafter are optional. When flex dollars are utilized for health care, salary contributions shall resume until minimum funding requirements are met. All contributions to the flex account are tax deductible and excess contributions shall be permitted within statutory guidelines. Flex dollars shall roll over at the end of each fiscal year and never escheat for lack of utilization in a fiscal year. Once the insured becomes eligible for Medicare he may, at his option, withdraw any remaining funds in similar fashion as to a Traditional IRA. Further, upon insured's death, any remaining funds in said account shall pass through his estate.
    The cost of each individual's catastrophic plan shall be determined by his/her personal risk factors such as disproportionate body mass index, substance abuse, criminal record, participation in high risk behavior, etc.and adjusted annually.
    Any premium amount attributable to personal high risk behavior shall be the sole responsibility of the individual and not the employer; unless such risk is job related or the employer waves the exemption.
    Thus the individual will now have a financial incentive to engage in a healthier lifestyle and be more fiscally responsible in the procurement of care.
    The patient will have no restrictions as to what MD he chooses to see.
    He will also be motivated to shop his care and actively inquire as to the need/cost/quality of services and durable goods provided.
    In essence the responsible segment of society will be self insured, his choices will be greater and his costs will be less.
    Insurance fraud committed by any provider, insured or carrier will have severe civil and criminal penalties imposed.
    The government will provide indigent care facilities for those individuals too poor or unwilling (self employed or retired non-indigents) to buy into the private plan.
    The government plan will:
    1. provide basic health care based on ability to pay.
    2. be immune from all acts of ordinary negligence
    3. be staffed by residents who must complete a two (2) year rotation at an indigent care center with minimal compensation before being eligible for licensure in private practice AND be supervised by board certified attending physicians.
    4. only provide generic medication unless brand name is deemed medically necessary
    5. require that all non emergency patients who present to an ER be triaged by indigent care providers assigned to that facility
    6. prohibit paramedics and other emergency response providers to transport non emergency indigent patients free of charge. Public transportation will, however, be provided as deemed appropriate.
    7. prohibit coverage of chronic life support, organ transplants and other extraordinary measures that are a result of poor behavioral decisions; ignorance will not be an excuse for bad behavior.
    However, nothing will preclude any person from independently paying for non covered health care of himself or another so long as it is not illegal.

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  28. PART III:
    The FDA will be more cost effective in permitting products to market while continuing to provide for reasonable consumer safety. Common sense will replace a warranty mind set.

    BUT instead, Obama and his Congressional whores are setting up a government co-op for the delivery of medical care that will make the aforementioned Indigent Plan look like a Cadillac.
    Long lines, rationed care, and third world caregivers from Pakistan will be the benchmark for every American except the liberal elite Politburo.
    How long would your local grocery store stay in business if their customers could fill as many buggies as they wanted with whatever products they wanted for a $20.00 co-pay? Would you expect the quality of goods to go up under such a plan? Would you expect rationing?
    How about if restaurants or car dealerships conducted business that way? Twenty dollars for whatever's on the menu--Steak and lobster or a burger? Pick a car for twenty bucks--a Bentley or a Honda?
    How insane.

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  29. a lawyer with a special warfare pin who is for tort reform and injection of market forces??? i think i have my first ever man-crush. ok... it scared me and it has passed.

    APPLAUSE

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  30. 911,

    I appreciate the compliments.

    My experience has taught me to never expect gratitude and thus minimize disappointment. However, when ingrates degrade Americans and our way of life it tends to piss me off. Grumpy RN's comment,"... it confirmed that most Americans seem to be oxygen thieves and are probably too stupid to live." begs the question as to where his f'ing little island would be without the USA? Sprechen Ze Deutsche Nurse Grumpy? I didn't think so....thank an American soldier for that.

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  31. Well I did ask for intellectual so thank you Black Ink, unfortunately almost all of it is irrelevant to me or what I have been commenting, but some answers.

    Curious why you would call me an ‘ingrate’, so far on this blog my dealings with Americans have given me nothing to be grateful for.

    So typical of an American to bring up the war. It ended 65 years ago, get over it.

    I did not denigrate America or Americans until after I had been abused, threatened and treated to some serious stupidity. Sometimes it takes a sledgehammer and a bit of exaggeration for effect. Oh, and which American soldier should I thank? The (special forces) one who recently killed a Scottish aid worker being held hostage by throwing a fragment grenade at her? See here, http://www.bbc.co.uk/news/uk-scotland-11596339 and here, http://www.bbc.co.uk/news/uk-11551594

    I bow to your superior political knowledge re Marx, but I fail to see what that has to do with anything I have written. I have not once brought up politics and certainly not communism except when I tried to point out a well known American habit of equating socialism with communism. I have nowhere said that the UK or European system is better than any other, I merely pointed out that different systems exist with different priorities. I am unsure why you would bring up the British Empire? This is history and nothing to do with anything nowadays, you may as well bring up Spain or France and their colonial aspirations. Oh, and when you say bloody England........ I am not English and don’t live or work there.

    Lifting something verbatim from my blog and posting it elsewhere is just poor etiquette and as you are a lawyer perhaps you can tell me where I stand as regards copyright? I don’t remember giving you permission to use this. At least you acknowledged where it came from. However, in the spirit of international relations feel free but if in future you wish to copy a whole post and not just a sentence or two I would appreciate being asked first. My post was a condemnation of a management team which wanted to have nurses work a 12 hour shift for free with no choice in the matter – in this country this is taking the piss.

    As I am unsure of all the details of health care reform in US I cannot comment although you seem to have some good ideas in there.


    Mid west Woman

    Many thanks for your kind words and your support, it was not my intention to insult all Americans, merely the numpties that seem to inhabit this blog. As you can see when you commented, you immediately became a target for their stupidity and abuse. I have met many Americans and most have been friendly and civilised.

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  32. sounds unfair to me... I mean working a whole twelve hours without a choice... so i suggest you fall back on what you said originally here... that those of us providing health care should primarily be motivated by a humanitarian desire to help our fellow humans and that bringing money or concerns about money into the argument was typical of the ugly American health system which, is, by the way, still providing the best care in the world to all of our citizens AND thirty million folks who are 'undocumented guests'. obviously a situation that is not sustainable but, the only reason we can provide 30 minute door to balloon stenting to anyone regardless of their ability to pay is because of the robust nature of our system built on a capitalist model. and 'the NIH is doing just fine thank you' seems like, well, a steaming turd of a lie. it's gotta hurt to be called out for being, not just grumpy, but a grumpy crank of a liar. you came here and tossed a grenade, sorry the blast hit you, I'm sure you can get seen for that in a month or two.

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  33. Angry Nurse:

    1. Your post is not copyrighted.
    2. Your post was re-published here in its entirety to demonstrate your hypocrisy.
    3. Your request for me to seek your permission is denied.
    3. When the Brits and their step-children (e.g. the Scots et al) need to be rescued from the grip of Islam we all know who they'll call.....the same boys from ST6 who you are so quick to criticize without any knowledge as to what REALLY happened in the Afghan desert rescue you referenced.
    "Although the special forces were able to find Ms Norgrove and shield 10 women and children from fighting, Ms Norgrove was killed." Collateral damage is regrettable. However, to imply that ST6 "threw a frag grenade at a hostage" is an intentional misrepresentation of a material fact.

    Lockerbie demonstrates the Scot's contrasting view of how to deal with terrorists.....it's time for you folks to stop whining and man up or in the alternative shut the F up about those who stand up when you stand down.....

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  34. Are you 6? I ask because you seem to take delight in changing my name and title throughout, behaviour I would expect from children. I am not angry, I am not an LVN (whatever that is), I am not an MD (a qualification which does not exist in UK). I am what I said I am, a middle aged Emergency Nurse Practitioner who thought that he could make a simple comment on a blog with an example from a different system and has received abuse, political dogma, threats, stupidity and ignorance since.

    Lockerbie has nothing to do with this discussion and I suggest you read the facts, not the crap that comes from Washington or London before you bring it up.
    USS Vincennes - the direct cause of the Lockerbie bombing, civilian aircraft with civilian passengers shot down and the captain is decorated....?

    What are you going to throw at me next? perhaps that you won a war in 1777? Or was it 1776? I forget, but hey it was against the Brits so let's use that to abuse old GrumpyRN.

    Who is doing any whining? Again, what are you talking about? You go off topic, off subject and from what I see, off planet.

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  35. I have taken my dog for a walk and had some fresh air and realised, I have had enough of the nonsense, the rubbish, the stupidity and the ignorance on this blog. When people bring terrorism into a medical blog I realise, I am never ever going to get you to understand anything apart from your own small world. So yes, if you want to think of it that way, you have won, you have worn me down. As another blogger has on her site - "Never argue with stupid people, they wear you down with experience".
    I did try to delete my last comment but your blog won't let me.

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  36. I prefer "Never wrestle with a pig... You will merely get dirty, and the pig will enjoy it." OBTW we will be taking a vote shortly on our most prestigious award, and at least from my perspective, you have earned it. Stay tuned!

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  37. dear BLACK INK,
    i don't know what you are talking about with islam overcoming the Brits or what-eva... except for this.

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  38. Grumpy RN, sorry to be so late in responding, but I ignored all your posts cause I thought you were an RN and thats what I do with RNs, except for the one I married..(taking big breath) I'd be Grumpy too if I lived on a 3rd World Island with an Ugly Queen, and her Mongoloid Son who looks retarded, and who's Consort Mistress(marrying her doesnt change the truth) has teeth even a homeless crack Ho in America would turn in horror from,
    The same shite-hole who's ass we had to kick TWO times to get y'all to stop makin us drink tea, drive on the left, and like Soccer, then we were cool, and even though you stuck your crooked Limey Noses in our Civil War, OK, you were on the Good Guys(South)side until the North got that bad call at Shiloh, and even then we let bygones be bygones and saved your Blood Pudding Eating Asses from the Germans not ONCE but TWO Times, and just because you beat the ARGENTINIANS in the Falklands doesnt count...
    And to conclude, Shakespeare's Overrated, Masterpiece Theater is just a bunch of fags prancing around in pantyhose, and Benny Hill is...
    Ummm he's actually funny.
    and your Heavy Metal Bands are pretty good...
    But whens the last time an Englisman won the Daytona 500?????
    So go away boy, ya bother me, go watch the changing of the Guards Jockstrap down at Buckminster Abbey...

    Frank "Prince Charles Buggers Little Boys" Drackman"

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  39. And its just not me who wishes Truman hadn't wasted those 2 A-bombs on the Japs...

    "The Sun never sets on the English Empire because God would never trust an Englishman in the Dark" Ernest Hemingway, 1917

    "An Englishman will burn his bed to catch a Flea" umm don't see whats so bad about that one...I hate Fleas...

    "England will fight to the last American"
    (sarcastic American Military phrase from World War 1, I mean World War 2, I mean World Wars 1 AND 2)

    "All Englishmen talk as if they've got an eighteen inch schlong stuck in there throats, and then after swallowing, they get constipated from the pits" W.C. Fields

    and your only real Statesmen of any note??? Winston Churchill? 1/2 American(and 1/4 Jewish BTW see Jerusalem Post article 15 Jan 1993) and you can thank his Hebrew Blood y'all aren't Spreckin the Freaky Deaky Deutsch..
    HIS MOTHER WAS AMERICAN!!!!!!!!!!!!!

    OK, Kate Moss is pretty hot, if you don't look at her teeth.

    Frank "U-S-A!-U-S-A!"

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  40. Jesus, Frank, what you smokin' boy? Gotta stay out of the drug cupboard.
    Now that my friends is a rant of epic proportions. Who needs sense when you can spew that much bile. Jingoism, Xenophobia, Racism, Sexism, Homophobia. Remember my comment about Oxygen thieves? You have just met one. And, he really, really is too stupid to live.
    Frank, son, you missed one important point I made; I AM NOT ENGLISH! Oh, and by the way, surely the RN at the end of my name was just a bit of a clue as to what I do? Also, twice I have written I am a NURSE practitioner.

    Frank? Since 1945, what wars has US won?
    Korea - still ongoing, call it a draw at present.
    Viet Nam - I was around then, I think you guys got your ass kicked,
    Grenada - OK you won that but they sure are a real superpower.
    Gulf War 1 - Finished with the job half done, so at best a draw.
    Gulf war 2 - ongoing
    Afghanistan - ongoing and I can assure you that like the Russians, UK and US are going to get out of there with their tails between their legs.

    911 - Curious as to why you think I would think Mohammed is bad. As-Salaam-Alaikum.

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  41. did someone leave a window open?

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  42. Oh, so you CHOSE to live in Eng-a-Land??, whats the matter, things get to hot for you in Ireland, or Scotland, or the ISLE OF MAN, which has got to be the gayest name for an Island, where was I, oh yeah, if I was wanted for buggering little boys, I'd probably go to England too...cause you'll fit right in in "Merry" old England
    and we don't have Drug "Cupboards" in America, Andy Cap. Seriously, your Cap looks just like the one Andy Cap wore in the comic strip "Andy Cap" and he was always drunk, and getting his ass kicked by his homely wife...
    Oh yeah, its the 21st century, we don't have "Cupboards" we have these things called "Pixuses" where we keep our controlled substances, and you got me, "Laudanum"s a much cooler name than "Morphine" and I like "Paracatomol" too cause the rubes don't know its just tylenol.
    Ironic that you criticize the very oountry, that if it didn't exist, Du wirst diesen Satz auf Deutsch mussen lesen, und was fur einen Arschloch,
    Oh, I'm sorry, you don't have to read German, cause we saved your Asses TWICE!!!!!!!!!!!!!
    and speaking of getting out with tails between legs, 2 words..
    YORKTOWN!!!!!!!!!!!!! oh wait, my Bad...
    DUNKIRK!!!!!!!!!!!!!!!!
    you remember that one??, where your Army abandoned its weapons on the Beach rather than fight the Germans???
    and I could keep going with ignomious English defeats ummm does 4-1 ring a bell??
    June 27th, 2010 when the Germans beat your drivin on the left asses in the World Cup...
    and FYI(that means "FYI") the Brits fought in Gulf War 1 too, I know, I was there

    and even if you were an American, Male Nurses are just wrong, I mean Gay, not that theres anything wrong with that(but there is)
    now go listen to some WHAM!!!! before I get serious and bring out the big guns, which you can't legally own in the UK....

    Frank "Princess Di was a Slut" Drackman

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  43. It's not a non-sequitur, you dolt, he's implying that a window was left open and a pesky fly has entered the room. The fly = (duh) you. Quite clever actually.

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  44. Ummm gotta side with Grumpy, I didn't get the Open Window thing either...

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  45. dear frank,
    too obtuse? i know you don't do subtle... can't wait for your next... kinda like henny youngman and sam kinnison on crystal meth. i dig it. do you think our friend may be from one of the outposts of the empire?

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  46. Frank, Frank, Frank...........what can I say, I am truly in awe. I love your invective, a mixture of verbal diarrhoea and Tourettes’. A combination of hatred, bile, argumentum ad hominum (yes I know I've used that before but it bears repeating), lies, half truths, facts, nonsense, bad grammar, and sh*t.
    What are talking about Laudanum, morphine and paracEtamol for, this is just random drug names and I know what a pixus is.

    3 days ago I wrote – “Oh, and when you say bloody England........ I am not English and don’t live or work there”.

    The correct pronunciation should be Eng-er-land when shouted out, not Eng-a-land. A minor point but one worthy of correction.

    I asked a question about wars post 1945 but you give me Yorktown??
    While we are on the subject of Dunkirk, I have a vision in my mind of Saigon 1975 and the undignified scramble for helicopters then those same helicopters being thrown overboard from the carriers.

    Football, NOT soccer, (6 billion people on the planet and only America calls it soccer, so by sheer numbers it’s football) I prefer 12th June 2010; England 1, USA 1. I laughed my ass off especially when USA went through as group leaders.

    I know that UK was involved in Gulf war 1, more UK troops killed by American ‘friendly fire’ than by Iraqis.

    In Afghanistan there are troops from all over, Canadians, Germans, Australians, Poles, and French etc. My point is that we should get out of there before more soldiers are killed – yours and ours. We are never going to tame the place. UK tried in 18th and 19th Century, Russians tried in 20th Century and now UK is back. I support the troops but do not support the war.

    Why are male nurses wrong? I have been a nurse for 30 years and have felt comfortable with my sexuality throughout, as has my wife and kids. I am afraid you are letting your redneck, bible-belt upbringing cloud your judgement, the world has moved on and homophobia is childish and nasty. Wham.........? Are you taking the piss? I have been into Blues and Rock since the 1960’s.

    I am not getting into a gun law discussion with an American we will never agree on that one.

    Anonymous – c’mon, if you are going to abuse me at least put your name to it.

    911 – I watched a video of Kinnison on YouTube, far too shouty for my taste but I see what you mean.
    Sorry, I am White Anglo Saxon born in Scotland. Hey I am also a protestant does that mean I am a WASP??

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  47. Grumpy..
    I notice you didn't respond to my "Andy Cap" putdown...gentleman-ly of you to recognize great put-down-it-ness-age...
    and theres a big difference between Dunkirk and Saigon...
    about 10 million Vietnamese...HAHA you know that was funny..
    Ummm I seem to remember after Dunkirk, Shit, DURING Dunkirk, we (USA! USA!) came to Eng-er-Lands Aid, and next time you go to France to pick up little boys, notice the thousands of graves of American Rednecks from Bible Belt Land...
    and did Eng-er-Land help us out in Saigon???
    Bueller??? Bueller???
    Thats an American-ism, like "Mo-Fo", Mo-Fo.
    And if it wasn't for the fact my Mom would have gone up one of the Chimneys at Auschwitz I'd have just as soon the Kraut's won WW2, which they would have, actually they would have won WW1, and there wouldn't even have been a WW2, if we hadn't bailed your limey asses out in 1917.
    Oh yeah, I forgot about the U.S. tying Eng-er-land cause no real Americans give a Shi-ite about Soccer, and don't give me that "6 Billion Chinese" thang, the Chinese shoot shoplifters in the Haid(American for "Head")and eat Cats too, and anyway, a ties like kissing your sister's friends, sort of hot, I mean like kissing your sister's husband, i.e. more horrible than having to look at Camilia Bowles Teeth...
    Which is why no REAL American sports end in ties, except in the NFL, and then only after 15 minutes of overtime, and if its the Post Season,they keep playing until someone scores or everyones dead.
    and whats the matter with "Wham"??? I was trying to find an area of agreement.
    and if Eng-er-lands so Homo-Friendly why does (Sir) Elton John live in Atlanta???Thats Right,
    Atlanta GEORGIA, UNITED STATES OF AMERICA, You Madman Across the Water.
    OK, probably because of the large number of young Hispanic boys who wont go to the police because there afraid they'll be deported...
    Gun Laws??? Thats why y'all got invaded in 1066, Whens the last time America got Invaded???
    Oh Yeah, by you guys, War of 1812, which I'm pretty sure y'all lost last time I went to a Baseball Game and listened to Our BEST NATIONAL ANTHEM IN THE WORLD, which is really just a guy describing how we kicked your asses.
    and whats YOUR National Anthem "God Save the Queen"? and not the Cool "Sex Pistols" version...

    Frank

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  48. i don't want to generalize, but all Scotts are worthless drunk, penny-pinching gits... but, uh, i think i'm Scotts-Irish... shit, never mind.

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  49. Only Scotchmen I can think of are Fat Bastard, and William Wallace..

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  50. Grumpy, You Sissy Welsh Rabbit!!!!!!!!!!!!!
    I'll give you this much, you certainly argue like an Engliahman, i.e. poorly...
    and little hint, next time you fight us, might wanta change the "Wearing Red and Marching in a Straight Line" thang...
    Frank

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  51. Frank - can we at least move to the 20th Century? I realise you are having problems with 21st Century but 1066? Get a grip man, guns not invented then.

    Wearing red? All nations’ troops wore their own colours except the colonials who being a mongrel nation did not know what colour they should be.

    1812 - typical Americans, declare war against a country that is already fighting a war.

    DURING Dunkirk??? Dunkirk was 1940, Yanks were not in the European theatre of operations until what? 1942? Lots of British and other countries graves too – you do not have a monopoly on suffering.

    God Save the Queen is the English national anthem and I suggest you Google it for all the words and not just the politically correct ones that are sung nowadays. Catchy tune though don't you think seeing as you guys have stolen it for some dirge you sing.

    It should be Welsh RARE-BIT not rabbit.

    Baseball, just rounders (a kids game) played by adults.

    China has 1.3 billion people not 6 billion – I did say on the planet.

    Andy Capp? Figured that was just rhetoric and did not require an answer.

    Frank, you are getting boring with the childish abuse, argue sensibly or stop.

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  52. Grumpy,
    and you look more like Sneezy...
    "Argue Sensibly"???
    Thats why Y'all(American for "You All") lost your Empire, except for Gibraltar, Wow, 2.5 square miles thats good for nothing, at least you can imprison A-rab terrorists at Gitmo.
    and I won't even mention losin to India, heck, at least the Vietnamese can fight.
    Seriously, you got your Asses Kicked by Ghandi...
    Thats cause we Americans had to steal, I mean take our Country from the REAL(Making "Tomahawk Chop" gesture) Indians, the ones who run Casinos and sell tax free Cigarettes.
    OK, don't thank us for World War 2, or World War 1, we're used to it, and anyways y'all saved our bacon in.....
    Bueller??? Bueller???
    (Crickets Chirping)
    OK, y'all did lend a hand in the Gulf War, not exactly the Somme or D-day, but its a start.

    But just to show there's no hard feelings, I really loved "Braveheart", especially the end when Mel Gibson kicks the Britishes Asses...

    Frank

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  53. WW1
    British killed 703,000
    British wounded 1,663,000

    USA killed 117,000
    USA wounded 204,000

    WW2
    British killed 357,116
    British wounded 369,267

    USA killed 291,557
    USA wounded 670,846

    WW2 civilains killed
    United Kingdom: 92,700
    United States: 6,000

    I'm not quite sure what we 'owe' you but we paid in blood.

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  54. Not sayin you "Owe" us anything except maybe for some of those Lend-Lease Destroyers, I'd sorta like to have one of those out on the lake...
    and its like Patton said..
    "No Bastard ever won a war by dying for his Country"
    You gotta make the OTHER BASTARDS Die for THERE Country!!!!!!!!
    "Patton" great movie, and FWIW(that means "FWIW" Patton hated Y'all too)
    Or at least that Montgomery Blowhard...
    Yeah, You Brits died...
    FOR YOUR OWN COUNTRY!!!!!!!! Just like the Russians, French, Canadians, bla bla bla.
    Americans died for YOUR Country, whens the last time y'all did anything for us???
    Bueller?? Bueller??
    That would be "Never" and don't tell me about Joe Shit the Ragman from Liverpool who joined the US Marines and won the Medal Of Honor...He only came here like Beckham did, cause why would ANYONE stay in England if they had a choice...
    Frank "Your makin me rethink my position on the IRA" Drackman

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