Saturday, April 02, 2011
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medicine because the all-important Standard of Care, what was once the collective wisdom of effective physicians has been replaced by the frightened knee-jerking of the weakest among us, that is, those who have been sued once too often or are beaten down by one too many patient complaints and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?
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.
Posted by Ailuropoda at Saturday, April 02, 2011