The Lack of a Liberal Arts Education

I do not know the author of this piece in EP Monthly and bear him no personal animosity. The fact that it was published at this time seems to me to be an alarm-call about what is to come with our health care system.

A friend of mine has written a rebuttal, and has been rebuffed in his attempt to get it published, so I am including it below in full.

Notice, if you will, that Dr. Hochfeld demonstrates a few things in his apparently dispassionate plea for a government fix. The two that strike me are the logical fallacies that run throughout, not the least of which is an amateurish and shallow view of what a 'right' is and what a 'right' means in this country, but moreso, the fact that if one does not accept his initial premise, that 'basic health care is a right for all' that the rest is pap.

I do not accept his premise and neither does the good doctor below. Dr. Hochfeld's 'solution' to our 'crisis' would have been lauded by Marx himself, but this doesn't appear to bother him or those who responded favorably to his proposal. It is unconstitutional on it's face, also, apparently not a big deal for the author or for our president-elect.

I weep for the people of this country as Che-Guevara-esque portraits of Obama are being posted in the hip cafes of this great land. We are witnessing the birth of a cult of personality. Without further ado, I present my friend, Dr. Tarkovich, a boarded EM physician with a tour in Afghanistan under his belt and a knowledge of history and logic that destroy Dr. Hochfeld's arguments like Oprah destroys a doughnut.

I want to comment on Dr Hochfeld’s article on health care reform, as I see some major flaws with his reasoning. I think the problem that most people have when trying to solve the high cost of health care in this country is that they have trouble stepping outside of the current paradigm. Free market health care would not work within the current system, but where is it written that the current system cannot be changed?

First of all, people do not have a right to health care. Dr Hochfeld claims that “access to basic health care is a right,” but then goes on to say that certain physician services are included in that right. There is no way that a person can have a right that infringes on the rights of other people. These are called positive rights, and are morally flawed. A person can have a negative right- the right to be free from harm by another person, but health care requires that other people provide goods and services. If I have a right to health care, the doctors, nurses, pharmacies, and drug companies will have to give me their product and service for free, which infringes on their right to be compensated for their labor. What do you want to do to people who refuse to give away their work for free? Steal money from them in fines? Put them in a cage? Once you force someone to work for free, that person has become a slave, which is prohibited by our Constitution. Claiming that people should have a right to health care is akin to saying people should have a right to food and therefore all restaurants and grocery stores must give their products and services away for free. Is the government going to pay for these things? How will they ration those dollars and determine who is deserving? Will they also throw money at another commission with a top-heavy bureaucracy? What if a physician does not want that money with all those strings attached? Is he or she free to make those decisions, or is the doctor forced to provide that service on penalty of being fined or jailed? The socialist system cannot work without threats of violence. Am I the only one who finds that troublesome?

Dr Hochfeld makes the argument that the suppliers of health care have too much control over the demand. I agree with him, and this is where the free market could take over. Why does it cost $800 for someone to come to the ER for an uncomplicated broken arm or laceration repair? Why can’t someone spend 6 months to be trained in simple procedures and make a living in his or her own private clinic? No, there is no medical degree being given, but they can let the free market determine if they are doing a good job. They have a great incentive in that they will go out of business if they do shoddy work. Before you suggest a regulatory body to oversee this industry, think about how much the costs will go up to fund the bureaucrats in this endeavor. We are trying to keep costs down, and the free market is very good at that job. I am sure these people would be happy to receive $50 for minor cuts and breaks, and they could even use dangerous drugs like: lidocaine, tetanus boosters, and cephalexin. We have a monopoly on services in this industry, and the free market cannot exist without competition. What would hospitals do to compete with this new sector? They would have to lower prices. If a person wanted a thorough physician evaluation, he or she could choose to pay more. Much in the same way you decide what to eat for dinner or what type of television to buy, cost plays a role. People make decisions about their health based on cost all the time (types of food, cigarettes, alcohol, saturated fats, etc).

Additionally, Dr Hochfeld proposes a system with a salary cap for specialists. This is akin to complete socialism without allowing market forces to determine salaries. Karl Marx’s “labor theory of value” says that value is determined by the amount of work required to produce a product, not the consumer demand. This fallacy means that a surgeon who labors for six hours and finally removes an inflamed appendix should get paid more than the adept surgeon who removes it in 30 minutes. Guess which doctor will have more consumer demand and be worth more money in the free market? When we try to fix things with central planning, we are marching down the same road that caused the downfall of the USSR. No central body can ration health care dollars because no one can predict market pressures and respond to consumer demands as rapidly or as efficiently as the free market. In order for our system to work in the free market, we would have to remove the current restrictions that allow for monopoly privilege of physician services. Dr Hochfeld claims that he is looking for a way to make physicians work harder; the answer is competition.

Pharmaceutical companies are also hampered by FDA restrictions, which make them take almost 20 years to get a new drug approved. They in turn have to charge ridiculous amounts of money for their product to recoup these costs and strategically hold off on releasing medications until they have exhausted the prior one. For those of you who will argue that this is for safety, I urge you to look at the number of drugs that came to market and were later found to be extremely harmful. What is wrong with publishing data and allowing physicians and patients to decide? Are we too stupid to make those decisions? How long would a drug company be in business if they produced a drug that harmed many people? No one would buy his or her product and the owner could be held liable in court as well. When was the last time a member of the FDA got sued for approving a drug that was harmful?

Finally, on the issue of care for those who need it and can’t afford it, I bring up the absurd notion of “charity.” We are all human beings, and most of us in this line of work have compassion. Personally, I donate a large amount of money to charities every year; charities that I feel do an excellent job. For those of you who think the government is the best charity to handle this endeavor, look at how carefully they handle your money and how efficiently they produce things like new roads and highways. Do you want more “evidence-based” medicine like blood cultures in uncomplicated pneumonia? (Hopefully the sarcasm came through in those comments). The free market would do a much better job of caring for sick people than our current socialist system. Wouldn’t it be great PR for a hospital to have an entire charity wing? I think a doctor would acquire many more patients when it became known that he or she spent even one day per month doing free care. Of course, the legal system would have to be drastically revamped in my world, but that is a topic for another time.

When the system you propose requires that you use a word of violence like Tsar, it is time to rethink that system.

Consults Circa EMTALA

PHYSICIAN TO PHYSICIAN CONSULT PRIOR TO EMTALA

Dr. A: Hey Bill, I've got a patient down here that has a lung mass. She has no insurance and no job and is quite distressed. She needs a biopsy and maybe surgery and chemo. Can you help?

Dr. B: Well jeez doc, my schedule is full for the next few days, but maybe I can work her in between appointments on Friday. Tell her not to worry, I'll see her in my office. I'm sure we can get her plugged in.

Dr. A: Thanks Bill, she really feels badly about not being able to pay you much and her husband says they can pay some over time... They are really nice folks and will try their best.

Dr. B: Yeah, okay, probably won't see a dime but let's get her in. I'll ask the oncology folks to get involved too. Jim will jump on this. Maybe we can fix her.

Dr. A: Thanks so much. See you at dinner on Saturday, got a few days off coming up.

Dr. B: See you then.


PHYSICIAN TO PHYSICIAN CONSULT POST-EMTALA


Dr. A: Hey Bill, I've got a patient down here that has a lung mass. She has no insurance and no job and is quite angry. Had to wait three hours to be seen and all. She needs a biopsy and maybe surgery and chemo. Can you help?

Dr. B: What, am I on call for the ER?

Dr. A: That's what it says on the schedule.

Dr. B: You guys are killing me. That's four patients over the weekend that will cancel my clinics on Tuesday. You guys just cost me over five grand from paying patients.

Dr. A: Yeah, us too. Thirty people waiting to be seen. Twenty walk-outs today. Eighteen ambulances and four of them reasonable calls. This woman was actually diagnosed with a lung mass last year but never followed up. Still smokes. Came in tonight because she's been coughing up blood. Says she 'can't afford to see a doctor so she came here.

Dr. B: Fucking incredible! What does she think that the ER is free?

Dr. A: It is free to her. She will never pay for any of this, says she's disabled. Drove herself in, has a cell phone that she's been talking on half the time I've been in the room. Seems quite unconcerned except for the wait. Says her lawyer said to come here and that we have to treat her.

Dr. B: Do we?

Dr. A: Yes.

Dr. B: Lawyer?

Dr. A: Yeah, she's suing the poor sap who took her chest film a year ago. Says he didn't explain the consequences of the XRAY findings to her adequately... says she didn't understand this was dangerous. Went to the lawyer before coming here.

Dr. B: Holy shit, now I really don't want to take care of her! Hey can't you transfer her to the General?

Dr. A: No, EMTALA prohibits it.

Dr. B: But she can't sue the city hospital but she can sue the hell out of me! Can't you get Dr. C to take this one?

Dr. A: No, his privileges are suspended for not signing his charts on time.

Dr. B: Suspended for not signing charts?

Dr. A: Yes.

Dr. B: Well, come to think of it, I haven't signed my charts in a while. Maybe I can get suspended too?

Dr. A: Worked for him.

Dr. B: Can we get oncology to consult?

Dr. A: They aren't on call tonight?

Dr. B: Well will they help out after the biopsy?

Dr. A: Don't know, you will have to ask them, we only heave oncology ten days out of the month.

Dr. B: Fuck this! I knew I should have gone to business school. I can't wait till I retire. Just so you know, I'm seriously considering dropping my privileges and doing all outpatient stuff, surgery center, the whole bit.

Dr. A: Join the club. Sorry.

The Bill of Rights

All this talk about a right to free health care got me kind of mad because I didn't believe it existed under our constitution. I also thought that patients should bear at least some of the burden for maintaining their own health and paying a reasonable fee either for insurance, or to physicians who treat them. Boy was I wrong! Witness the genius of America!


The Bill of Rights


Amendment I Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the government for a redress of grievances. And all humans within the border of the United States have a right to free health care.


Amendment II A well regulated militia, being necessary to the security of a free state, the right of the people to keep and bear arms, shall not be infringed. Health care for free is a right for any organism with 23 chromosomes found within the borders of the United States.


Amendment III No soldier shall, in time of peace be quartered in any house, without the consent of the owner, nor in time of war, but in a manner to be prescribed by law. Doctors are required by federal law to see and treat all patients regardless of their citizenship, state of intoxication, assaultive behavior, or ability to pay for said care.


Amendment IV The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no warrants shall issue, but upon probable cause, supported by oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized. Doctors are to accept 30 cents on the dollar for their services. Dentists, Complimentary and Alternative Medicine practitioners, chiropractors, and life-coaches are to be reimbursed at 100 cents on the dollar.


Amendment V No person shall be held to answer for a capital, or otherwise infamous crime, unless on a presentment or indictment of a grand jury, except in cases arising in the land or naval forces, or in the militia, when in actual service in time of war or public danger; nor shall any person be subject for the same offense to be twice put in jeopardy of life or limb; nor shall be compelled in any criminal case to be a witness against himself, nor be deprived of life, liberty, or property, without due process of law; nor shall private property be taken for public use, without just compensation. The right to free health care is universal while in any state, territory, or possession of the United States. The right to payment for goods or services delivered is universal except for physicians who are greedy, rich bastards and should be held in the lowest esteem especially by the uninsured, addicted, politicians, liberals, and attorneys.


Amendment VI In all criminal prosecutions, the accused shall enjoy the right to a speedy and public trial, by an impartial jury of the state and district wherein the crime shall have been committed, which district shall have been previously ascertained by law, and to be informed of the nature and cause of the accusation; to be confronted with the witnesses against him; to have compulsory process for obtaining witnesses in his favor, and to have the assistance of counsel for his defense. The right to sue physicians for negligence occurring in the delivery of free health care shall not be abridged unless the physician guilty of negligence is employed by the United States Government, in which case the plaintiff is shit outta luck dude!


Amendment VII In suits at common law, where the value in controversy shall exceed twenty dollars, the right of trial by jury shall be preserved, and no fact tried by a jury, shall be otherwise reexamined in any court of the United States, than according to the rules of the common law (except for physicians, who may be forced to settle lawsuits by their insurers or surrender their privileges, or insurance and therefore their ability to practice). Also, it is hereby mandated that physicians have no right to sleep, or to the pursuit of happiness.


Amendment VIII Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted. An exception shall be made for physicians, especially physicians in training, who may be imprisoned by their hospitals and kept awake for up to 72 hours at a time while performing surgery or fetching stool samples.


Amendment IX The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people. Did we mention that primo allopathic health care for all is a right?


Amendment X The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people (physicians excepted, of course).

Can I Get Prior-Authorization To Kick Your Ass?

Whoever decided to put high-school dropouts in front of a computer with headsets on to speak with physicians or medical providers to discuss and approve or deny drugs or other therapies for patients was a real fucking genius.

Let me tell you how it usually goes when I try to get a wonderful, newer drug approved for my patients. I love Byetta and prescribe a ton of it. It is the only commonly-used drug for type 2 diabetes that lowers glucose AND helps patients lose weight. Unfortunately, since Byetta is newer and more expensive than your typical, cheaper generic diabetes drugs that cause FURTHER weight gain in these already-obese patients, it often required pre-approval from insurance carriers. We'll start with how the prior-authorization call usually goes (in reality), then we'll slide into the 'Twilight Zone' where both me and the insurance company customer service rep say what we actually WANT to say to one another.

Dr. Lofty: Hi, I was asked to call to get prior approval for Byetta for my patient.

CSR: Yes?

Dr. Lofty: Yes?

CSR: And your question is?

Dr. Lofty: My question is, what information do you need to get this drug that I believe my patient should be on approved?

CSR: Yes (pause, looking up algorithm for questions to ask caller under 'Byetta protocol'), so why does this patient need Byetta?

Dr. Lofty: Because they have gained 20 pounds over the past year on Actos and glyburide and in my experience I can get this patient's hemoglobin A1c down about 1% with about 20 pounds of weight loss using Byetta and getting them off of these other drugs.

CSR: I see. And what is the medical justification?

Dr. Lofty: I just told you the medical justification.

CSR: Yes, well, I'll need to fax over a two-page prior authorization form that will need to be filled out completely along with the last three chart notes documenting failure to achieve control with....

SLIDE INTO TWILIGHT ZONE...

Dr. Lofty: Hey fuckhead with your G.E.D. diploma hanging on your cubicle wall, I went to fucking medical school for four years, did three years of residency training plus a chief resident year, and have been practicing diabetes almost exclusively for ten years. My experience tells me this patient needs Byetta and I want him to have it NOW! Losing weight and shrinking the waist probably reduces cardiovascular risk in patients with type 2 diabetes.

CSR: Sir, we really don't give a flying fuck if your patient loses weight. We would prefer he or she remain on the cheaper, generic drugs that they are currently taking.

Dr. Lofty: Well, the patient sure would feel better in the long run losing twenty pounds and losing about 2 gallons of fluid from their legs.

CSR: Again, don't give a shit about this patient's quality of life. Too expensive to use this drug. This person won't be on our plan in two years, so we could give a rat's ass whether or not they lose weight or feel better. They'll be someone else's problem in two years.

Dr. Lofty: You're a dirty fuck stick...I hope you gain 200 pounds today and develop type 2 diabetes. You'd be begging me to put you on Byetta and I would give you shitty drugs like glyburide and Avandia to make your fat ass fatter!

CSR: Whatever. You doctors are so arrogant.

Dr. Lofty: Hey, Einstein. Can I talk to your supervisor? I want to get the ball rolling on a prior authorization to come down there and kick your sorry little ass!

Sue Me

Ethics be damned, I finally did it. I worked the overnight recently and one of our executive class frequent flier patients showed up in the waiting room at 2am. Dr. Deborah Peel (the patient) was, evidently, prepared for the fact that our ER cocktail lounge had been closed for a bit so she tanked up prior to arriving. Her chief complaint was that she was "really going to do it this time", as in, she was really, honest to goodness, no kidding and no reversies, going to off herself.

All she had done toward that end was polish off the better part of a fifth of Old Grandad with some valium as a chaser and yank out stitches one of my colleagues had placed in her wrist (very superficial wound) the week earlier. Apparently not happy with how quickly she had been brought back to a bed she 'fainted' out in triage and when I was called to see her in the room she had the "I've just seen a ghost" stare and was very good at it. Just as an aside I could well have said that it appeared that she had just had an encounter with the 'numinous', which is my favorite new word, but let me go ahead and tell the rest.

After I jammed a Q-tip most of the way past her turbinate (nasal passage) and she persisted with the stare I gave her narcan and she woke up a bit. Turns out narcan does occasionally have an effect on severe alcohol intoxication and this woman did not have opiates on board so that was interesting. It took about two minutes to figure out that she wasn't going to die within the next 5 hours so I felt a lot better. I ordered tests and meds and went to the next patient.

The next patient had his face mangled by a big dog. The patient and his girlfriend were extremely nice and I really enjoyed helping them out. The repair took me about 45 minutes and I had big flaps of facial skin to realign and the lip to put back together in two places.

As I was actually doing something worthwhile with the dog bite guy the aforementioned woman kept yelling that no one was doing anything for her pain. Debbie (as I call her now) denied being in pain when she 'woke up' so that, along with the fact that she was as drunk as Cooter Brown made it inadvisable to giver her pain meds. She would not leave her nurse alone though. Finally the nurse had to act so she came to me and I nodded conspiratorialy before she said anything.

ME (within earshot of drunk lady): "Wow, it sure sounds like she's hurting, better give her something strong... Why not try 650mg of paracetamol, but tell her not to take it unless she wants to sleep because it's so strong (wink, wink)".

NURSE: "Oh doctor! Are you sure???"

ME: "I think it will work and I think she needs it".

Paracetamol is tylenol (as the Brits call it). The patient asked what the pills were, she was told they were paracetamol and would make her sleepy etc... and like a good patient she swallowed the tylenol and promptly went to sleep.

Ethicists would probably say I abused my authority and engaged in deception. I don't agree as tylenol is a pain medicine and I would argue that I was setting the patient's mind up for successful treatment. In fact, I would argue that I was using CAM and that it worked like a charm.

The dog bite guy did well and he and his wife winked at me knowingly when the snores started from the adjoining room. CAM rocks!