"Buck" and Modern Medicine

Buck Branaman  is a genius. And the movie "Buck" is worth watching over and over. It's a movie in which you will meet a man like many who chose medicine WANTED to become. Mr. Branaman is one of the worldwide experts in horse-training and he's much more than that, he's probably the best human psychologist I've seen in a long time.

Now the thought struck me while watching one particular part of the film that Mr. Branaman would have quit his profession long ago were it not for the fact that people who seek his services do not compose a huge voting block and, as far as I can tell, pay him for what he does. Some actually save money for years to go to his clinics. Wow.

I can picture the moment when the government decides that all horses have a right to Buck Branaman's time and expertise, pass laws about how he may go about delivering his service,s and how he may be reimbursed. It's going to be the same day that he retires. I mean the way he treats the owner of the renegade Stud-Colt at toward the end of the film is not only a HIPAA violation, it is very POOR customer service, will generate a complaint, and the poor woman's money will have to be refunded.

EXCEPT... EXCEPT!!! The woman herself was grateful for the upbraiding she received and said, after, and through some tears, "He's right.... he's right.... I do have problems I need to fix and the horse is only one of them."

So I'm picturing myself saying something similar in the ER, "No sir, I am not refilling your pain medicines, you have problems which you are covering up by taking them and you are lying to me in order to try to get them from me, now, I can either call the cops on you right now, or I can help you find the help you need, but I am NOT refilling your narcotics."

For me, another job lost. But, thankfully, not for Buck Branaman.... not yet at least. Sometime after EHTALA is passed by congress.

Inmates and Asylums

As a segue to Panda's 'Heroes of the Revolution" screed, and with synchronicity, this email just found it's way into my inbox. It is from one of the ERs where I occasionally make a cameo as a highly sought after expert in emergencies (like running out of your oxycontin on a Friday evening). This email has been only slightly altered from it's original form and this is, exactly, what ER medicine has come to, and I believe Michael Moore would be even worse as a patient than this toolbox, but that's another story. The "customer" in the ER is always right, and this is true even when, outside of the ER, and exhibiting the same behavior, they would be arrested and taken to jail, or beaten to a bloody pulp with abandon.          

 

 

Effective immediately:

When Michael Moore presents to Bumfoodle ER, immediately notify Bumfoodle Police Department. Request officers be dispatched to the ER to supervise the entire encounter.

If possible, avoid all contact with Michael Moore until officers are present. The exception is if Mr Moore has an obvious life or limb threatening emergency or has been without a hamburger for more than thirty minutes. In this circumstance, use caution and never deal with Mr Moore by yourself.

Mr Moore's repeated demands for narcotics, violent behavior, and threats of bodily harm are not to be taken lightly.

'Pain Scale' Kills Patients

All of us who practice in the hospital setting and probably those of you who practice in clinics are familiar with the 'visual analog pain scale'. I wrote a bit about it on 3/17/07 (can't get a link to work... you can search the blog under 'arithmetic' and get right to it).

I got to thinking the other day, as I wrote out another prescription for Lortab for someone with "ten out of ten" pain, that one of the unintended consequences of the 'visual analog pain scale' has been a huge overprescription of narcotics and the skyrocketing of drug abuse by people who would not otherwise do it. After all, it's from a doctor, no?

I can't pull a .jpg image off the web for you but someone got a few million dollars from the NIH to come up with this 'scale' which is a series of human face caricatures progressing from smile to frown. You then ask THE PATIENT which one represents their pain at that moment. That's it. Science?

At the same time that one of my former employers was taping the pain scale to the back of every chart (at the behest of the 'Joint Commision' or JCHAO, or whatever they call themselves these days), and dinging us for not using it on every patient, the admin-weenies who are, almost to a man, not physicians, started dinging us for 'customer service complaints'. Usually these complaints were about the treating physician's refusal to prescribe narcotic pain medicine. Getting it from both ends, most of us just shrugged and came to some reasonable middle ground. My middle ground is that I will prescribe ten Lortab, no refills, to just about anyone. Sorry... that's just the way it is.

So this little theory of mine was quickly (partially) verified by a google search. Interesting, no? Oh those unintended consequences!

There are those who will still fight this battle... but with every patient that we fight we spend more and more time and field more and more complaints, and it's a wonder some of my colleagues still have the energy.

Medicine is an art and a science, and the assessment of pain can not be reduced to a silly-ass, third-grade, completely subjective cartoon. Docs, why did we surrender to these buffoons? We surely did (in almost all areas of the practice of medicine) ... but why?