Saturday, April 02, 2011

Resistance is Futile

Until the End of the World

Some problems are just unsolvable. This includes most of the problems facing our nation as well as the Medical profession. There is no way today to practice good, rational, and more importantly, cost-effective medicine because the all-important Standard of Care, what was once the collective wisdom of effective physicians has been replaced by the frightened knee-jerking of the weakest among us, that is, those who have been sued once too often or are beaten down by one too many patient complaints and in capitulating, ensure that no patient, no matter how minor their chief complaint, is not met with a full battery of imaging and testing. If you order a CT of the brain, a chest film, an EKG, a battery of cardiac tests, a chemistry panel and a complete blood count on every patient you theoretically wont miss much but the cost...Dear Lord the cost.

In fact, I have received a few patient complaints and many of them essentially boil down to, "That doctor didn't do nothing," after I sent them home with no testing and no strong medicine. I have also on a few occasions, in the course of a thorough history and physical exam, been interrupted by angry family demanding that I shut up, stop wasting time, and order some tests. It's magic that they want; wonderful, deeply satisfying, mystical American Medical Magic. Blinking lights! Blood tests! Xrays!

"I just came in to get checked out and since they didn't have a medical testing vending machine in the lobby you'll have to do."

Neither am I immune to the seductive urge to just order a bunch or stuff that I know will be normal to both mollify the patient and temporize a little so I can get some charting done. I've given up fighting quite a few things, particularly the patient with a long history of hypertension who checked their blood pressure at Wal Mart and, finding it a little high and with no symptoms at all, present to get "checked out" with a blood pressure in triage of 150/90. I generally order a bunch of tests and the results are always essentially normal whatever that means in the arc of the patient's eventual journey to a heart attack or congestive heart failure.

I can't admit every 49-year-old with high blood pressure and no symptoms, can I?

Can I?

I still don't treat non-symptomatic high blood pressure (unless it is really high) and I can show you chapter and verse in our Textbook of Emergency Medicine where it says not to but who knows how long I can resist the temptation to capitulate? I mean, I need my job as much as anybody...more so because I am paying back huge loans and a long-suffering and decent woman who couldn't stand being married to the man who sacrificed her, the principle treasure of his life, for nothing and less than nothing...sacrificed her to Medicine, a profession that to my sorrow and regret I have realized was not worth one single tear from her beautiful eyes.

So what's to be done about the downward spiral of medicine to mediocrity, from rationing by the expert judgment of a physician to that coming from some vague government department?

Nothing. Nothing to do. So long as the nation is a puppet to lawyers and bureaucrats and the hardening tyranny of the parasite class there is no solution. The expert clinicians who I admired as a medical student and resident, who judiciously consulted and tested to confirm what their history and exam told them, are either extinct or nearly so. I've made a mighty effort, even deciding to work locums (sort of like a wandering Ronin Samurai) so as not to get assimilated completely into Corporate Cult of the Twin God, Mammon and Press-Gainey, but the Center Will Not Hold and one day they will pin me down. I will become a bland, smiling, Doctorbot presenting the menu of testing and treatment to the customer, hardly daring to gently, ingratiatingly and humbly make a few timid suggestions.


  1. Yeah Medicine sucks, Jews are stingy, Black men steal, tell me something I dont know, like,Why do you have huge loans? Didn't you go to med school in Lousiana? I mean, I took out a low interest NDSL to, but to buy a motorcycle,(88' Suzuki 750 GSXR, that I drove through downtown Atlanta at 145mph cause the throttle stuck:( cause I got paid TO GO TO MED SCHOOL!!!! Thats right, Uncle Sam paid my whole outrageous $25,000 tuition(for 4 years) along with $500/month to blow on beer and cigarettes...What a sucker...
    OK the 4 year delay in residency, that turned into 8, cause I enjoyed wearing a flight suit and not treating anything more serious than planters warts, wasnt exactly professionaly enhancing, but I wouldn't trade that weekend with the 4 el-Al stewardesses for all the Interventional Endocrinology fellowships in the world...
    OK I've done my share of inappropriate medical testing so I could watch the last inning of a Braves game, there was this one time I got the charts mixed up, and sent a 41 week G21P12,5,5,3 for a CT, carotid dopplers, MUGA, Spiral CT, Cardiac Enzymes, Telemetry, and sent the 60 year old Truck Driver with chest pain and dizziness for a Non Stress Test...
    Guess you had to be there...


  2. I confess I don't understand you or your blog.

    Panda Bear

  3. PB, I've missed you dearly. As a MS3 getting ready to apply for EM residencies, your blog and posts have mentally prepared me for the goat rodeo. I couldn't think of doing anything else in medicine. And I look forward to using the SOCMOB acronym. Any advice you could throw my way to prepare for the gloomy road ahead?

  4. Advice:

    Be kind to your patients, even the drug seekers...not saying give them drugs but walk into every room with an open mind and let compassion be your default setting.

  5. Don't give Demerol to patients who you aren't going to admit. It's like swatting a gnat with a Chevy and most people who ask for it are drug seekers.

  6. God damn that was a good piece of blogging. Where the hell have you been and why are you tagging along with these folks? Missed you terribly.

  7. advice: save your love & compassion for the people you spend time with when you are not at work. medicine is no longer a calling. it is just a job. those animals that come in snarling and spitting serve only the purpose of paying your bills. don't spend time outside of work thinking about work. use it to make yourself whole again, to regain what you lost during the training process.

    two final pieces of advice- work on feigning compassion as it will come in handy, and it's not too late to look for nonclinical work.

  8. hey fiz,
    go fuck yourself. i mean in a nice way... gently... or hard, depending on your particular preference. i'm guessing you like it hard, but to each his own.

    right on, man. right on.

  9. I still think it's a calling. It's just getting harder to and more difficult to do the right thing. I don't know where you all live but in my town I get a lot of respect for being a physician and while it is certainly a job, it is also a very different kind of job.

    But you have to act the part and all it takes is to be compassionate without being syrupy, firm without being a tyrant, and knowledgable without being a smart ass.

    I'm sorry I ever got involved with this profession but I'm in it and I'm going to enjoy the few benefits as much as I can.

  10. Panda, and I mean this in a kind/compassionate/loving/non-demerol dispensing/syrupy way..
    Whens the last time you got laid?
    cause you sound like me back before I discovered rufies, I mean met the woman who taught me about love.
    and then I met my Wife, Whoa-oh!!!!!!!!
    "Sorry I ever got involved with this profession"
    them's pretty strong words, now when you don't post for a few days everyones gonna think you went all Ernest Hemingway, I mean Kurt Cobain, except Kurt Cobain was friggin Richard Simmons compared to your happy face...
    Its like I told my Dad, who hasn't smiled since 1972, coincidentally, the only year he got to do what he loved doing, dropping high explosives on Vietnamese, "Don't worry Dad, there's always another War" I said, and there wasn't one until after he retired...

    Hope that helps, now I've got an appointment with a heart shaped box...


  11. Frank, what on Earth are you talking about?

  12. gotta side with frank here panda,
    and i don't think you are being truthful when you say you don't understand him, though i do think you are being truthful when you say you don't undersand his blog... i mean from Isralei Army beaty queens to 'glee' to medicine to football and back... it's a wild ride.

    but frank is what used to be called 'a real character'.... he has a schtick, and, evidently, it serves him quite well to keep him from focusing on the black, dark, ugly things in life.

    he's part henny youngman, part ron white, part sam kinnison (sp), and all American. he's a redneck jew for goodness sakes... one who is way into football and served 8 years in the navy and seems to have a good time, all the time, which, as far as i can remember, only the 5th drummer from spinal tap was able to do (the one after joe 'mamma' besser).

    and i think he may just have a point. i mean no one here disagrees with you Panda, but i have found that after a year OUT of the ER working only a shift or two a month, that i can't write like you are writing anymore.

    if you are stuck in the gulag (and, my friend, you ARE stuck there)... then work on planning your escape. that is unless you want to ride the nuclear bomb down to the missile silo like slim pickins in Dr strangelove. it's tempting i know, and i'm not kidding about that, and doing ER medicine SHOULD be a calling, and i don't even think it is forever lost on the scale of the ER or on the scale of American medicine, or on the societal scale... but i have regained perspective.

  13. i practice in an area that gets a lot of nyc patients. i assure you in spite of my post that i still have more respect for them than they do for me. but why should they respect services that are "free?"

  14. Joebob,
    I can't possibly come up with the words to proclaim the absolute truth of what you are saying. It is, perhaps, the most insidious thing wrong, not just with the ER and it's tentacles, but with our culture. HOO-fucking-RAY. THE most important thing in people's lives, and we give away the life saving stuff (and the minions and drones who dispense it- a that is how we are viewed now), gratis. STOOPID. Or and evil plot at world domination... Not kidding about THAT either.

  15. Panda, I'm gonna share something a bitter General Surgeon taught me in 1987..
    and sidebar, does anyone here remember what a Great Effin year 1987 was? Ronald Reagan in the White House, 70cents/gallon gas that I thought was outrageously expensive, T'Pau, Bangles, Prince on the FM, and Ecstasy was Legal, OK, I don't mean 100% legal, but it wasn't Ill-Legal(at Bushwood)like it is today... Where was I, oh yeah, Georgia...
    Whenever some free-loading patient treated him like a Servant, refusing to leave the Hospital/ER/Clinic, sit up, cough, bla bla bla, he'd slip into this fake "Rochester" accent, Jack Benny's old Negro Chaufeur,
    "Wats Evah, y'all says Boss" he'd say to whatever patient was being difficult, then he'd leave it to us to pull out the staples the old fashioned Gestappo way, I'd even say that I was gonna pull the chest tube on the count of "Three" and mess em up by countin in German, "Eins, Zwei, HERAUS!!!!!" which would really confuse them, cause they were waiting for the "Drei" that never came...
    Hope that helps,


  16. hell, i might even be able to make peace with the state of things if i was actually "giving away life-saving stuff" as you say. i could delude myself into thinking at least i am making a positive difference.

    what i'm giving away instead is... i don't even know what it is, but it isn't life-saving. 3 weeks of dizziness, tingling to the lips, sometimes with chest pains, some time with nausea, sometimes just weak all over. can't explain in further detail because i'm busy talking into my cell phone and eating the mcdonald's i stopped for. why are you here?? why is it my fault if your bizarre constellation turns out to be serious???

  17. Well, that was kinda depressing. But while what you say is true in many aspects, can you name another job where there is not the same degree of B.S. involved? Every job has things about it to hate, that's while its called work and not recess. But this job, despite everything you said above, is still 100x better than the next one on the list, at least in my naive point of view.

  18. "So long as the nation is a puppet to lawyers..." I keep coming to the nauseating realization that lawyers run the country and most seem to be in it solely for their own gain. The laws are made by legislatures made up almost entirely of lawyers. Lawyers as litigators and judges are the last link in the chain that enforce the laws. Our chief executive is a lawyer. Lawyers now monopolize every branch of government at virtually every level larger than a hamlet. It's no wonder Pres Obama wouldn't even consider tort reform as a part of the health care bill. That would be putting a salary ceiling on everyone in his beloved profession. Malpractice law just exemplifies Sutton's law - lawyers love malpractice cases because that's where the money is. Wasn't there a time when military heroes went into politics and were successful? Makes me wonder if that's what we as a country need.