I Swear It's Dead but Give me That Stick Anyway (the Unintended Consequences of EMTALA)

Anonymous makes a good point in a comment on my "Can't Stop Poking it With a Stick" post:

EMTALA dates from what, the mid 1980s. Didn't you
know about it when you were choosing your specialty? Knowing about it, why did
you choose a specialty where you're most likely to be hit hardest by
it?

My answer was long and rambling and you may read it if you wish, but the easy answer is that Emergency Medicine interested me and was the best fit for my inquisitiveness and short attention span. Jack of all trades master of none. That's me.

Here I would like to compile a list of the unintended consequences of the unfunded federal mandate called EMTALA. To my nursing and physician colleagues please add to the list as you see fit.

My primary objection is voiced much more eloquently at "Movin' Meat" (click title above to see his EMTALA post) and is, essentially, that EMTALA is nothing more than theft by legislative fiat. Under penalty of law we MUST see all patients with an "emergency condition" or face jail or financial loss. It does not apply to dentists, chiropractors, massage therapists, aromatherapists, shamans etc... Here is my short list of what flows from this communistic scheme...

1. Cost Shifting: Medical treatment has cost. Someone pays. EMTALA has shifted the burden of payment for the uninsured onto the insured, taxpayers, insurance companies, and doctors. As a result, it's harder to get insurance, our taxes go higher, the number of uninsured has skyrocketed, insurance rates have skyrocketed, and doctors make less money. I know, poor rich doctor right? I'm 46 and finished paying off my school loans five years ago. If I keep at this for another 15 years I can retire comfortably (unless I screw up at work and get sued). If you want to get rich and sleep well then stay the hell away from medicine. If you want to work in a tremendously demanding field with high pressure, responsibilities that increase every year, and pay that does not keep pace with inflation then medicine is perfect for you!

2. Insurance Tomfoolery: Since I don't work in the insurance industry I will only say that with my current insurance a medicine that I take daily costs $90 per month cash and $93 per month with my insurance. My taxes, even with the "Bush Tax Cuts" are 33% of my income. I work harder and faster for less money every year, and, when I find an out to a less taxing (in all senses) profession I will take it. I am not alone.

3. Physician Shortages: Speaking of doctors leaving the profession lots of irreplaceable talent in medicine is opting out of the system. Surgeons train for AT LEAST five years, and that's just to do general surgery. Their debt load out of residency can approach $300,000. To do a surgical sub-specialty add $100,000 of debt, a divorce or two, and three more years in the black hole. You can replace an office manager by posting an ad on Monster.com, you can not replace a neurosurgeon or cardiothoracic surgeon if no one is willing to go through residency hell. In other words, these fine humans have to, at least at some point, believe that the sacrifice will be worth it and not just in financial terms.

Now, with EMTALA, specialty surgeons are dropping their hospital privileges like hot potatoes and opening up surgical centers. I don't blame them, if they sign on with a hospital then they have to take ED call and any drunk asshole who falls off a bar stool and breaks his leg at 3am on a Sunday has just blown the whole day for the orthopedist on call. All his paying patients are bumped from his schedule so he can take care of the patient in the ED. I live in a town of 200,000. We have five orthopedic surgeons. Five years ago we had six. Next year we will have four.

We do, in fact, have three plastic surgeons in town. None will maintain privileges at the hospital. So now your complicated ear laceration will be repaired by, well, me. I'm not bad, but I'm no plastic surgeon.

Interventional cardiologists? We have one. We have been trying to recruit another for three years. No one will come here because of the Emergency Department and the burden it would place on them to give away care. How much is it worth to save a patient dying from a heart attack? The answer is a number greater than zero, really, it is.

4. Increased Demand for ED services: The uninsured public has learned over the years that the ED is free (and that you don't have to be a US citizen to take advantage of it). What I mean is that when they are treated in the ED they get a bill which they never pay. Since they have no money and no credit there is no way to collect and no consequences for using the EMERGENCY DEPARTMENT as the "SNIFFLE AND WORK EXCUSE DEPARTMENT". Our collections, a bit below average for Emergency Departments across the country, are about 28 cents on the dollar.

5. Encouragment of Personal Irresponsibility: Because the uninsured public has come to rely on the free care we provide their health maintenance needs are not met. Consequently I often see patients whose untreated hypertension has resulted in a stroke or heart attack. Often there is no one to blame here but the patient and EMTALA. If you had to choose paying a few hundred dollars a year to see your Internist or FP to manage your chronic medical conditions AND you had to pay for your medicine wouldn't it be really easy to fall into thinking that it doesn't matter really because if you get into trouble you can just go to the ED? Believe it or not this truly is the way people think. If you doubt me just look at the number of people who still smoke and don't give me any crap about "evil tobacco companies". People choose and at least in the ED they have usually chosen poorly. Who should pay for this? EMTALA doesn't say and its silence is deafening.

6. ED Overload: Because the ED is the place of first and last resort now for huge numbers of uninsured we physicians are battered by the need to sort through piles of the unsick so that we don't miss anyone who truly has an emergency. In our ED we saw 70,000 patients last year. It was renovated in 1990 to accommodate 25,000 patient per year. Oh, and by the way, you better not miss anything in one of the "unsick" or you will get a letter from an attorney, or, what's often worse, a patient complaint.

7. Nursing Shortages: Because of the now ridiculous demands of the ED, nurses are fleeing. They are not paid on a production basis. They are not supposed to have more than a few patients at one time and they are supposed to focus on the patients they have. The nurses save our asses time and again because they have good clinical judgement AND they spend a lot more time with our patients than we do. It is routine now at my institution to lose a nurse a month and, if they can be replaced, they are replaced by newbies. The only way to make the ED work now is for nurses to cover each other and see each other's patients while they do all manner of extraneous tasks (patient transportation to the floor for instance). I wouldn't work one day in the ED as a nurse. It's unsafe. Congratulations voting public, your government representatives have legislated you into a "guinea pig for newbie nurses" status at many of our EDs. Now before I get a lot of hate mail from nurses let me be the first to say that there are many great newbie nurses out there, but that all of us need to learn to drink from the fire hose that is the ED under supervision.

8. Health Care as a Right: EMTALA, like all the other wonderfully successful government entitlement programs has, WOW, produced a sense of entitlement in the uninsured! As a direct result of EMTALA many people who can least afford to get sick do not think it is their responsibility anymore to either make good choices about their health or pay for the consequences of their bad choices.

9. Bad Math: EMTALA says 2 does not equal 2. You see, because of the need to cost shift, doctors are now payed based on government and insurance company fee schedules. These basically say that a $900 procedure is reimbursed at, say, $250. Now that's new math! I am looking forward to the application of EMTALA to the auto industry so I can finally buy a BMW.

10. Bureaucratic Asexual Reproduction: Lots of full time government jobs created to police EMTALA. Lots of lawyers happy. Lots of politicians elected for giving away other people's stuff. It's easy, after all, to give away other people's stuff, especially those pretentious, rich, selfish doctors. Many of my patients do not deserve the care they get on the back of the taxpayer, but as William Muney (Clint Eastwood) says in Unforgiven, "Deserving's got nothin' to do with it."

The Specialist Wall

American Medicine will die or be reborn in the next ten years. Correction, it will either continue an accelerated slide into banal mediocrity, or be reborn. The battle is finally joined, and it has been joined by the specialists. Thank you, doctors, for drawing the line in the sand. I hope you win. Honest.

I am cheering against my own college here because they have been so obviously wrong for so long, and our leadership, such as it is, has continued to try and put a hammer-lock on our consultants by passing resolutions and amending hospital bylaws and throwing guilt trips at these most-skilled physicians. All of this instead of making sure the stars are in good shape for the big game. All of this instead of advocating for physicians and fighting against EMTALA.

If you are unfamiliar with EMTALA or our take on it you can read about it here, but to be brief, EMTALA is an unfunded federal mandate passed in 1986, which, de facto, has made it a crime to tell anyone 'no' in the ER. Because of this, the specialists on call have learned to hate the ER. The ER is no longer a place from which one can build a practice, it is, rather, a place that compels you lose sleep, and money. It compels consultants to expose themselves to full malpractice liability EVERY SINGLE TIME they accept a patient from us whether they ever get paid or not.

No doubt there is a strong tradition in western medicine to treat first and seek payment later. This dates to Hippocrates and is part of the original oath. My question is this. How far should this obligation extend, AND, should it be extended by force of law rather than by individual choice? My answer is that the obligation should never be extended de jure. Medical schools, training programs, and hospitals can choose to extend this requirement to their students and physicians and the students and physicians can choose to participate or not, but the government does not have this right. Seems to me we fought a war over a similar issue, for this is analogous to taxation without representation, only this tax is paid in time, liability, AND money (and it never ends).

But let me take the opposite view and say that creating the obligation to deliver care gratis to whomever is sick in the ER during your on-call shift IS a proper government function. The next question is this... How much exactly? How many charity cases are you required to do per year? Is the answer, "as many as the situation demands"? It can't be that because then you have made medicine into a charitable endeavor, and maybe this is what it should be, but it is not what it is, and not what it was, ever, anywhere. This is not to say that there are not physicians who aren't motivated solely by charity, but it is to say that there aren't many of them. If it's not "as many as the situation demands" then what is the answer, and who gets to decide?

So the specialists are fed up, and they have figured out how to fight city hall. For years their battle has been against the system or even the ER doc downstairs. But now (oh the genius!) they have turned the bureaucrats game against them. EMTALA and the bylaws, policies, and rules that it has generated are being followed to the letter.

For instance, almost all hospitals have an on-call policy for specialists that require them, if the ER doc requests it, to come in to the ER and evaluate the patient. Well, they can be forced to do this, but in many cases they CAN NOT be forced to treat the patient. Unheard of twenty years ago and before EMTALA, but specialists are now routinely coming in, evaluating the patient, and finding reasons why this particular case is out of their area of expertise, or not appropriate for their care, or not in need of surgery immediately, and the specialists are going home.

Recently, a child came in to the ER after sustaining a facial laceration. Two different surgeons were called to fix the cosmetically sensitive but clearly non-emergent laceration. Both came in, and both told the ER doc, "No issue, you can do this." And that's exactly what happened- the ER doc sewed it up (I hope he did it well). And that's exactly what EMTALA means, and exactly what Obamacare means, and it ends up hurting people who do not deserve it, and it ends up rewarding those that do not deserve it. And yes, I said "DESERVE", and yes, I mean it. Punishing the doers eventually causes them to slip the yoke.

But how can a surgeon refuse to operate? Well, well... by way of example, consider the lowly gall bladder. When I was in training the gall bladder came out with pain and an abnormal ultrasound. Now it doesn't. It used to be that surgeons would operate at the drop of a hat because they loved surgery. Not anymore. You see, if a patient with acute cholecystitis can be 'cooled down' with fluids and antibiotics, VOILA!, no need to remove it right now. Have the patient follow up with the surgeon as an outpatient. You can't be sued for an operation you didn't do.

Then the patient goes to the surgeon's office a few days later and is no longer under the rubric of EMTALA, therefore, they must pay for their surgery (payment plans are accepted), or have insurance. Still sounds fair right? I mean, who gets surgery for free, right? Well, these folks do NOT follow through with the surgeon because it's not free, they end up right back in the ER, and on the 28th time they are sick enough to go to the ICU. Some of them die, and they ALL chose to walk the streets with the ticking time bomb in their belly because they wouldn't pay a single dime for surgery (but they happily pay ATT for their I-phones).

EMTALA compliant? Absolutely. Fair? Yes. Optimal? No. How to force the surgeons to operate? I don't know... at the point of a gun? Otherwise, there's no one that can do what they do, not even an attorney. Surgeons, in particular, are unique, and they are needed, and so sorry Miss Jones, but Dr. ___ has resigned from the hospital staff to open a botox clinic and no longer does procedures here.

And guess what? That's a royal fucking flush... the bureaucrats are holding a ten-high. No one else can do your jobs, docs... certainly not those who own us right now. Play your hand, specialists, the pot is huge and you can't lose. Bluff up the pot, get EMTALA in there, lay the cards down, and win a victory for yourselves AND patients. Be the wall on which the tide of enforced mediocrity and misery breaks. And let's get that plastic surgeon in to sew up the little girl's face... happily.

Georgia O'Keefe

Here's a Georgia O'Keefe painting called "Jack in the Pulpit no. I V." Nice.


On a completely different subject, what is it about physicians that makes us pussies? Somehow the previous generation of physicians rolled over and ate a huge shit-sandwich from the government called EMTALA. Our national organizations, the AMA, ACEP and the like, have acted like a bunch of perpetually-stoned good-time rock and roll maggot-infested hippies and have embraced the fucksticks at JCAHO too.

I know that the premed route is not exactly peppered with economics, logic, or business classes but please, you freaking douchebags, how in the name of all that is holy did you swallow the EMTALA and JCAHO pills? How, exactly, can you provide CABGs for all regardless of their ability to pay? The answer is, you can't, but while trying to accomplish this ass-hattery you will do it by having everybody else pay for it. In other places this is called stealing.

Could you not see, if only from a rudimentary common sense perspective, that EMTALA was going to crush you? Did you not know that when unfunded mandates have been tried previously, or their ugly father called communism, that they have failed miserably and made the situation worse?

Where were you, docs? Out on the golf course? Why were you not on the steps of Capitol Hill marching and carrying signs and threatening to strike? Why? Are you all a bunch of pussies or did you figure that by the time EMTALA ruined medicine that you would be comfortably retired? Damn your eyes for being clueless pussies because not only did you screw the next generation of doctors, you screwed the next generation of patients too.

That IS what happened, OR, in your feel-good liberalism you knew, you knew deep-down, that EMTALA would end fee-for-service and force a "solution" from above because you love government and its power and revere it with religious zeal. Better that all be in a similar state of misery than some have it better than others. OR, you were too busy working, and didn't think your colleagues and national organizations could be that stupid. WRONG!

Well good for you sunshine. Why don't you just move to some socialist heaven with closed borders and frozen social classes and live there. In the meantime you have made being an ER doc, or a doc that gets consults from me, an endless parade of entitled asswipe misery, and you have sucked the soul right from my body. You have wrecked specialty care for everyone outside of a big city. You have also wrecked the best care for the most system which we had and replaced it with mediocre care for all.

Happy now? I thought not, because there are still some in America who have more than others. Still, some rich folks get better care than that guy who ran his stolen car into a bridge abutment, drunk, while running from the police. How will you fix that? Why not go all the way and join the American Communist Party. Fucksticks. Have fun driving your Prius and drinking soy and wheat-grass shakes. Guess what? You are going to die too. Double fuckstick Deborah Peel in your face asswipe douchebags.

*** and thanks to my friend medblogaddict, for this post

Dada! Look at the Big Poop I Made!

Well I just love ACEP. ACEP is the American College of Emergency Physicians and they sit around and scratch their collective chins and wonder why those of us who work in non-academic institutions are so shitty. Here is an article which summarizes a 'report card' in which we get a 'D-'. I smell a set up for a bail out!

They even come up with some suggestions about how to fix our problems. Thank goodness.

My feelings about ACEP are detailed elsewhere but here's some refreshers. ACEP is the organization that has stood by and watched as EMTALA wrecked our health care system. They have never drawn a line in the sand, they have never pointed out that the inevitable consequences of EMTALA are the very problems detailed in the report.

It must be very heady to live in an ivory tower and speak in theoretical terms about the way things should be, here's the way things are...

1. Americans have come to expect their health care to be 'free' and EMTALA has made this possible.

2. Since you can 'always go to the ER', that's exactly what has happened, and ACEP has noticed that we are awash in uninsured patients who use us for primary care.

3. I have no idea what the Access to Emergency Services Act is, but unless it is a piece of legislation that puts at least a modicum of responsibility on patients to care for themselves and to find a way to either purchase medical insurance or contribute to the cost of their care it will be a disaster akin to EMTALA.

4. ACEP has made wonderful decisions in the past like getting television personalities to speak at their national convention and instituting the LLSA exam which requires us to pay them to take tests every year to make sure we are up to snuff on the latest bit of wisdom from the academy (like how the prevalence of rabies has changed in sub-Saharan Africa and how we can force our sub specialist colleagues to work for free).

5. ACEP, at every opportunity, has said 'how high' when the government has asked them to jump, and they lament that physicians are refusing now to give away their services and to weather malpractice climates in which the question is not whether one will be sued or not, but rather how many times.

6. ACEP has jealously guarded our specialty from other physicians who wish to become board certified but have not gone the traditional route. Let's be honest, a good family practitioner or internist can learn the critical skills needed to work in an ER in a year, and that's probably too much (if they train in a busy trauma center). And now, WOW! we don't have enough EM physicians. Three on this blog alone have quit full time ER work early in their careers due to the circumstances extant in the practice of Emergency Medicine that an organization such as ACEP could have averted had they even the germ cells of gonads in their collective body.

See you later ACEP. Thanks for nothing, and that pain in your ass... it's your head.

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.

Lemons From Spoiled Lemonade

If the health care bill passes, which everyone says it will, let's imagine the best possible outcome. The bill just might make it the best time in history to go into medicine.

You see, if you read this, you will see that the health care bill will give teeth to rationing. For me, a boarded ER doc, my job just got a lot easier.

Today, as it stands, you can be from Timbuktu (or Canada), walk in the door of my ER, and receive a coronary stent, a coronary bypass graft, or whatever is medically indicated. This is a result of the pre-Obama monstrosity of EMTALA detailed ad nauseum in other portions of this blog. It has nearly broken our system... NEARLY.

So EMTALA removed the onus from the patient to be responsible for himself both financially and health-wise, and put it on doctors and nurses. What better idea could there be then to remove the onus completely from the patient and place it on, well, people who pay taxes. Health care is now a 'right', but it will be like a 'right' to as much fool's gold as you want.

The dirty little secret for all you ER abusers is that your gravy train just went right through the station.

I now, along with my triage nurses, have teeth. You can now be turned away at the triage area if you haven't complied with the desires of the author's of the bill. Rather than ten hours of hell, my shifts now become quite regulated and predictable. EMS crews, guess what? Pretty soon you CAN actually tell people to fuck off. I imagine, that for a short time, it will be quite satisfying.

Initially, doctors should make a lot more money because the free care mandated by EMTALA will be reimbursed, theoretically, by you. The narcotic refill patients, the patients who can not see their primary care physicians and need reassurance regarding their chronic illnesses or perhaps a liter of saline for their gastroenteritis, will be sent home from triage. I won't see them anymore. They will be scheduled for the 'next available' appointment with someone, somewhere at some time in the future, probably three weeks or so.

So all you aspiring docs, you just got banker's hours. All you aspiring nephrologists, pick something else, dialysis as it is known today, will cease to exist for those with chronic disease. No doubt we will be very caring and provide comfort to those who will die, and when we can not provide a service or a procedure which is needed STAT, we can say, with sincerity, 'they won't let me'.

An Answer to Hugh Hewitt

Hugh Hewitt is a popular radio talk show host, an accomplished academic within the legal profession, a keen political commentator, and an evangelical Christian. He has dedicated this week on his show to physician callers, and asks, in short, what the hell we are doing sitting on our hands while Obama and his cohorts push to completely wreck the best medical system in the world, and thereby, our livelihoods.

I have an answer and it's hopefully not going to come off as an excuse. It is quite simple, I believe that after EMTALA was crammed down our throats in 1986 we all saw the writing on the wall and have simply been trying to muddle through to the inevitable.

This betrays a few weaknesses inherent in most physicians which are as follows. We are not lawyers. The legislature as it stands is populated by a huge proportion of lawyers who are schooled in the ways of legislation and politics, and we are not. We are schooled in what works and what does not. We are incredibly impatient as a rule, especially those of us in the ER. Get it done now or go away. When the monstrosity of EMTALA was enshrined the battle against universal health care was lost. How is the argument even made that we do not have universal care now? And how can one argue that there is a problem with access? I have not been able, ever, to turn a patient away from the ER.

You can be a murderer, an illegal alien, or a John Doe, pick up the phone, call 911, and get all your care (up to and including all manner of surgery) right away at the ER and never pay a dime. Why in God's name would we physicians, as a group, have any other belief than that the battle is lost and was lost some time ago.

Also, even though we have swallowed the bitter pill of universal care (without any legislative disincentive to abuse the system having survived scrutiny) our feeble attempts to bring even a small amount of sensibility to our tort system have been crushed in their infancy by the legal community, most often the American Trial Lawyers Association (and their willing accomplices in the congress). This puts us in the position of being forced to give extraordinary care to everyone who comes through the door regardless of their ability to pay AND bear the full legal consequence of any mistake made in their care up to and including 'pain and suffering' damages from 'malpractice'.

Also, we are not allowed to deduct the cost of this free care we give away, conservative estimates place it at $150k per year per Emergency Physician, and we are taxed in the highest bracket. The thanks are few and fleeting and the idea of mounting a legal challenge to universal care will have to repeal or revoke EMTALA which, I believe, to be impossible. It is impossible because the parade of sob stories before congress will succeed in painting us in the most monstrous light... money-grubbers who care not a whit for their patient's suffering, and the common sense response will be laughed out of Washington, namely that health care is not a right, and that everyone needs to be responsible for their own well-being at least to some degree. Obama has declared it a right for goodness sake.

Hell, Obama got elected by a convincing majority by PROMISING to redistribute wealth and who better to take from than the 'rich doctors'. The myth of the 'rich doctor' is easy to refute to those who appreciate logical argument, but there aren't many remaining who have not sold their souls for the sake of reelection. I know those with warrior spirits would not let this list dissuade them from at least trying to work the system to our benefit but here's the other part of how we arrived at this pons asinorum. Academic medicine.

As a general rule, the hard sciences produce more conservative thinkers than the liberal arts. I have no proof of this other than my own experience with attending law school for over a year and then switching to medicine. Out of my L1 class of 220 there were a small minority of conservatives. But in medical school I think we outnumbered the enemy by about 10%. I had found home.

As one progresses through medical training and residency the choice of whether to remain in the academy or go into private practice tends to split down political lines. There are a lot of advantages to remaining in academia. One generally makes a little less than in private practice BUT one has these convenient indentured servants called 'interns' and residents' who do all the 'scut work'. One is allowed, by this arrangement, to concentrate on writing papers and doing research. The life is attractive and I almost went, recently, back to the dark side simply for my own sanity.

However, it became evident in the interviews that, even at the august institution to which I was applying, the medical side of the academy had sold out to socialism. The attitude in the Emergency Medicine department is that our patients are SO incapable and stupid that we MUST do it all for them. The doctrine of personal responsibility is hard to maintain when you are treating the same person for the same thing for the 30th time that calendar year, each time the patient having called 911 to come in for their nonspecific overwhelmosis, and each time having the patient fail to comply with follow up instructions and fail to quit smoking, drinking, whoring, shooting up, or eating eighteen bags of cheetos a day. All of our national associations are run by the academics.

I understand this, but they are wrong. The end result of universal health care is not hard to discern, it is merely a lower quality care for all, and RATIONING of care. How could it be otherwise? The strong emotional desire to provide the best for all is merely a reappearance of the old Utopian dream, doomed to fail, because there is no one to pull the cart.

And this, Hugh, is where most doctors are. Most of us in private practice have given up trying to reason and argue with those who argue for a living. We are simply going to cut back on our hours, downsize our lives, and try to find other outlets for our talents. I admit that this is passive-aggressive in the extreme but it may be the only arrow in our quiver that will have any effect.

Unfortunately for patients, they will learn of their folly too late and there will be many people dying in 2012 who would not have died in 1990. Doctors, already a vanishing breed, will be on the endangered species list soon. Why would one choose to go to medical school now? Dear Mr. President, before you commit us to Universal Care you should ask if we are going to participate. I am not.

Thank you, Mr. Hewitt, for putting the docs front and center this week, and please check out the other conservative doctor's blogs listed on the links page here. We are simply looking for a leader and a command and a bit of hope and we will fight. Perhaps you can champion our cause? In doing so you will be championing the cause of every citizen of this country.

HEALTH CARE IS A RIGHT (AND FREE PUPPIES)

Sarah Palin, God bless you. John McCain, get off your ass.

Physicians suspected when EMTALA was passed that it was a set-up for a government takeover of health care in America.

The sub-prime meltdown is EMTALA writ large on our economy and the answer, after the government forced banks to provide mortgages to people that would not otherwise have qualified (here for example or simply click below) is, genius move, to get the government more involved.

Since Obama has declared health care a 'right' let me explain to those of you outside of health care what will follow if it is given a firmer foundation than it already has in EMTALA.

1. Care will be rationed. It's just that simple, all the other consequences are obvious, but this is the most important one for you.
2. Physicians will quit, retire early, cut their hours, or otherwise opt out.
3. The rich will still get excellent care either legally or illegally, but it will be unavailable for ordinary folks (see #1).

With a 'right' comes a 'responsibility'. If health care is a 'right' then who is responsible for it?

For the last twenty five years the answer has been the taxpayer, physicians, hospitals, and insurance companies (and the system has nearly broken under it's weight). When the 'right to health care' is enshrined along with 'life, liberty, and the pursuit of happiness' then, and this is not a bad thing at all for doctors (in theory, all the care we deliver will be compensated but at rates set by the government), 'the rich' will pay for it, and, 'the rich' will be defined by your government. The magic number for being rich, depending on who you listen to, is either an aggregate income of $250,000, or, according to the conservative media, folks making more than $45,000 a year.

I will make more money, initially, with an Obama-like plan, and I will not work as hard. It is idiocy. For many of you who are fairly healthy it will be great. When you get really sick, however, you will wait. Depending on where you live you may wait till after you die because there will be no incentive for hospitals or physicians to see more patients or to expedite treatment. In fact, if tort reform is not enacted with Obama-care, it will be a really bad idea to see more patients than your banker's hours allow, and a disincentive to take on difficult cases.

Welcome to the world stood on it's head. See you in line for free food. Farmers and grocers, you're next.

Reasons I'm Leaving Emergency Medicine (number 2)

This is a turd.

In medicine today this is what's known as a beautiful turd, a really nice turd, or not a turd at all, but something that only resembles a turd to the untrained eye. What this really is, according to those in charge today, is an opportunity to partner.

See, while I see this as a turd, this observation is not welcome. In fact, it may impact our Press-Gainey scores or our core measures, and this is unhealthy for the group and for the contract. The cynical amongst you might say, at this point, that those seeing this as a golden poo are merely motivated by money but no! They are motivated by a collectivist wisdom which is but a foretaste of humanity's next step up the ladder of evolution.

I admit that my feeble brain is not able to see this, so I am going to go hang out with other non-Mensans and other non-leaders.

To me, medicine today is a turd because we call patients 'customers', try to do better 'customer service' with all comers, most of whom do not meet the traditional definition of 'customer' (ie someone who pays for their services), worship at the feet of a terrible unfunded mandate called EMTALA, and also worship at the feet of a bunch of worthless committee hacks called TOFKAJCAHO (the organization formerly known as JCAHO).

We also shuffle money from the folks who actually gave more than a second's thought to their health to those who have made, and continue to make, poor decisions. In other words, there are tons of doctors and hospital CEOs and legislators who fancy themselves as modern-day Robin Hoods. They are not, they are the Sheriffs of Nottingham, but then again who am I to say, I think the thing at the top of this post is a turd

EMTALA has killed the best medical system in the world, and why? Because some douchebag legislators thought that it would buy them votes (and they were right). I also know how to fix our mess, but, since I major in plain-talk, I will never be elected nor will anyone who says this and here it is.

Everyone in the country should pay for their own medical care even if only for a small portion of it. Buy insurance or not, your choice. Get catastrophic coverage only and establish an HSA. Finance your care. Can't get insurance? There's no one to blame but the authors of EMTALA.

If you walk out of the hospital or out of the ER two hours after calling an ambulance AND you really have no money, no problem, we can arrange for a few hours of community service at the local free clinic. If "the government" wants to mandate that no one be turned away from the ER then let them pay for the care we are legally obligated to give or at least let us deduct it from our gargantuan income taxes.

Emergently ill patients should get our best and that's exactly what they get. They should then pay for what they received in whatever way they can. Insurance rates? Down immediately. ER waits? Gone. Bullshit EMS calls? Gone. Doctor retention and satisfaction? Up (and quickly). My job? Immediately better because I am not constantly presenting the golden turd to my consultants. In other words I'm for the good old American notion of personal responsibility. Hard in the short run, the only sane way to do things in the long run.

Pictured above is a turd. It can not be polished and there's no way to pick it up by the clean end.

EMTALA

So the government has written a law to prevent patient dumping. EMTALA, the Emergency Medical Treatment and Active Labor Act. This prohibits facilities from transferring patients with an emergency condition that could be cared for at the facility to which the patient presents. Of course it is not that simple. It is hugely complicated and well intentioned but as with most legislation the uninteded consequences are legion. The first is that it's an unfunded mandate. In other words we have to take care of all comers regardless of their ability to pay. Fair enough, we are in the business of Emergency Medicine and I personally don't care what someone's financial status is when they show up sick in my ED. But since this is a government mandate it seems only fair that the government would subidize this. No. We have just been ordered to lose large ammounts of money. How does this work? Cost shifting. Costs for everyone else go up and our paychecks go down. So sad you say... poor rich doctor doesn't get his money. Well, okay, but I'm damn good at what I do and I'm the one who might save your life. Is this skill deserving of high pay? I would say so, we are, I think, living in a free society where people chose careers based on reimbursement (and many other factors of course). I'm also the one that can go do just about anything else I want to do outside of medicine. You will eventually get what you pay for. Oh, just an afterthought, government facilities are exempt from EMTALA. Neat huh? Today we got a patient by ambulance sent 30 miles from an active military base. She crashed her car on the base and was a few hundred yards from their emergency department. She is not on active duty. They sent her here.

Paul Krugman, an Eighth-Grader at Princeton

Evidently Princeton University thinks enough of the economist Paul Krugman to employ him to teach in their hallowed halls. Evidently the New York Times thinks enough of him to have him write a regular op-ed piece for them. It was with no small amount of amazement, therefore, that I read his recent NYT screed linked above entitled Universal Health Care Opponents Have no Case.

Back in eighth grade I learned from a very wonderful English teacher and debate coach what an ad hominem attack was and that not only was I never to use this gutter tactic when engaged in argument, that I was, in fact, to allow any opponent who used it to speak freely and at length as they would kill their own side. As briefly explained by wikipedia an ad hominem attack... "is most commonly used to refer specifically to the ad hominem abusive, or argumentum ad personam, which consists of criticizing or personally attacking an argument's proponent in an attempt to discredit that argument."

For instance, if I were to begin the rest of this post as follows, you, my friend, would do best to quit reading... "Paul Krugman, "professor" of economics at Princeton, besides looking like a cheap version of Wolfman Jack, is also well known for spitting on babies and stealing pension checks from the elderly while pushing them down flights of stairs. He secretly hates women, puppies, and eskimos and for all the above reasons can not be trusted when he speaks about economics."

Imagine my surprise when this Princeton professor and New York Times columnist began a recent piece on "Universal Health Care" (again, linked above) with the following quote: "OK, it's not news that (President) Bush has no empathy for people less fortunate than himself. But his willful ignorance here is part of a larger picture: by and large, opponents of universal health care paint a glowing portrait of the American system that bears as little resemblance to reality as the scare stories they tell about health care in France, Britain, and Canada."

This guy is a famous economist? A Princeton professor? What follows in his article is a confusing mish-mash of pseudo statistics and anecdotal evidence (he cites a "recent Business Week article based on statistics and anecdotes") that our health care system is terrible because sometimes both the insured and the uninsured have to wait a long time for short term care. This is the best I can do at untangling this guy's logic. It seems he's comparing apples to oranges and complaining that the safety net which IS the Emergency Department is overcrowded and sometimes overcrowded to the point that that uninsured and insured alike must wait for a while to be seen. That's right, it's called triage, and thanks for the news flash professor.

To the extent that I can understand the rest of his piece it's no more than a pitiful attempt to gin-up an issue for the upcoming election cycle and confuse the public into believing that "universal health care" will solve all our ills. As has been detailed extremely well on Panda Bear, MD's site there's about a million reasons that this is a terrible idea. Having worked as an active duty military physician, a physician in the Veteran's Administration system, and in the private sector I can not imagine a worse idea than growing a government bureaucracy to administer a single-payer system. Do you enjoy going to the DMV? Are you a vet now? Do you get your care through the VA? Ever read about Walter Reed Army Hospital?

Krugman and his ilk, and pretty much anyone who comments on the current health care crisis neglect to mention what I believe to be the key factor to solving the majority of our problems. Patients, all patients, need to be made to be responsible for their health care. It is not a RIGHT it is a RESPONSIBILITY. Now there is ABSOLUTELY NO MONETARY INCENTIVE for patients to make healthy choices in their lives, to actually get a primary physician, to take their medicines as prescribed, or to get that operation they were told to get three years ago because THEY CAN, in fact, go to the Emergency Department 24/7/365 and have someone like me arrange it all for them.

The economics is simple. People have chosen to drop their health insurance OR have chosen not to purchase it because it is expensive (for me and my family of five we pay $460 a month) OR simply can't be bothered to open a phone book and call a doctor. Under EMTALA it doesn't matter, Emergency Physicians, Surgeons, and other specialists must see these patients in the Emergency Department regardless of their ability to pay, regardless of whether they are wanted by the police, regardless of whether they are in the country illegally, and regardless of the fact that many of them were seen just the day before for the exact same problem. And, as you know by now, the government that brought us EMTALA does not pay us anything for these donated services nor does it allow us protection from malpractice suits related to cases we treat under EMTALA.

When we make Emergency Department visits more expensive than a visit to the local pediatrician, internist, of family practitioner (and I mean collecting a small co-pay with EVERY VISIT) then the Emergency Medicine crisis will vanish. And no, what I'm proposing is not heartless, I'm not asking to bankrupt our underprivileged, I'm merely asking that they forego something, make some contribution towards their care, give up their 1800 minutes/month cell phone plan and settle on the 1400 minutes/month plan, give up their visit to the movie theater this week, don't get their nails done... you know, pony up $50 or so. It's amazing how behaviour changes when money is involved. I would think a brilliant economist like Professor Krugman would understand this, but then again he's just an ivy-league douche bag.

Extortion

Becoming a physician, thirty years ago, did not involve subjecting yourself to extortion. First with Medicare/Medicaid, now with EMTALA, and  soon, whatever bezoar is eructated out of D.C., a generation of physicians is being extorted. Furthermore, the impact of the extortion is not limited to physicians, rather, the impact is on all who need health care in America.

First, let me be clear that I am not one of these physicians, but I know lots of them. I know plenty of physicians who signed on the dotted line to commit themselves, body and soul, to medicine. They did it based on one of the fundamental principles of a market economy (and, doubtless, for many other reasons), that a fair price would be paid for excellence, and that their reputation and the price of their services would be determined by the most efficient distributor of resources known, the market. Also, they did it based on the belief, historically accurate in our country, that as a professional’s professional, they would have power over their careers.

It may be incredibly naive for them to have done that. In retrospect, my decision to join the service and have Uncle Sam pay the tab for medical school ($180,000 in 1992 dollars) seems like a genius move, but at the time there was no shortage of folks telling me I was making a big mistake. I joined for reasons other than money, but money was one of the reasons.

Coming out of medical school debt free has allowed me to avoid the trap in which many find themselves. *  It seems to be a trap that caught PandaBear and one that has caught many of my friends. The trap is extended and expanded through residency training by paying residents, per hour, minimum wage or less. During residency it is therefore impossible, especially if one has a family, to pay down your loans. Think about the interest over four years, or eight years, on $180,000 and then the size of the trap becomes clear. But the trap is only partially financial. The trap is cruelly protean.

Over the last fifteen to twenty years a quiet coup has taken place in medicine, with decisions regarding physician reimbursement, schedule, responsibilities, and the shape of a physician’s practice being co-opted by all manner of clipboard carrying administrative drones and academicians. Understand, I don’t believe the drones to be evil per se, they are simply doing what we can not… working to support themselves and their families to the BEST possible extent within their comfort zone. But their ‘normal’ existence and the laws, rules, and regulations which have allowed their rise, has come at the direct expense of physicians, and of patients.

The expense to physicians is in money lost from paychecks, but, more importantly, in confidence. The monetary loss is one thing, and it’s not hard to see how it happened… EMTALA and other government redistribution programs are unfunded, medical care comes at a cost, someone must pay, and the people paying the most are providers of the service (physicians), nurses, and taxpayers. Strangely, this redistribution has not only given to the poor (both deserving and underserving) and illegal aliens (by the hundreds of thousands), but has also given, from our pockets, cash to the new drone class in medicine. After all, there has to be a drone class to file the papers and hold meetings about how other people’s resources and money should be distributed. It has to be done with a semblance of “fairness” even though the act is unfair on its face.

Physicians have been a quiet bunch as their stuff has been taken, their time at the hospital increased, their power quashed, and their ability to practice medicine like they trained severely limited. Here is where uncertainty has replaced confidence. Here is where a whole generation of academicians and older physicians have given into bullying, or, worse, encouraged it.

I guess this is not surprising. It’s disappointing, but not surprising. It is one of the essential points of Panda’s post… what choice does he have at this point but to go perform at the carnival even though he belongs on Broadway (my words, not his). And the commentors either deride him for not liking the carnival, deride him for wanting to change it, or deride him for  'not being carnival material’. They say, “Well, leave already!” And go where? And do what? And pay his $3000- in school loans per month (for ten years) with what?

The Queen of the drones understands this calculus. The Queen demands more from the physicians, but the Queen does it in increments. So we physicians, and much of this IS our fault, have never recognized that once we surrendered to an emotional plea to implement price controls on some of our services that the DEMAND to give them away would surely follow. The funny thing is that, as a profession, we used to give away plenty of our services (perhaps more than we do now by law) prior to the rise of the Queen and her drones. Why do you think there are many hospitals called ‘Charity’? All that has happened is that we no longer get to experience the good feelings of providing charity care AND we have taken a pay cut so that tens of thousands of billers, coders, quality control folks, and ‘medical administrators’ can hold endless and pointless meetings which, ultimately and practically, become rules by which we must work. Guess what has happened to medical school tuition in the same time?

There are those who would say the medicine is greatly improved by the meticulous charting requirements and codes etc… I think medicine was better when your good family doctor could see you in his office, spend time with you, take care of you in the hospital, tell you ‘no’ or ‘you are too fat’ without fear of firing, keep your chart on an index card, hire a nurse and a secretary, AND be financially secure by doing this.

Patients complain that their interactions with physicians are limited and unsatisfactory. They are right, but they are unsatisfying for us too. We mightily wish it were otherwise; that we didn’t HAVE to see so many patients so quickly. We are operating in a perpetual crisis mode, but there really is no crisis. A crisis is not running-out of your Lortab. The ambulance is not needed to bring your child in for fever. A crisis is war, famine, drought, tornado, hurricane, heart attack, flood, severed limb, etc… In these circumstances it would be expected (and sensible), for all providers to have to scramble and keep moving, but the crisis is one of perception, and to the extent there is a crisis it is because responsibility for one’s health care bills has, for a segment of our population (which includes those in our country illegally) been eliminated by fiat. It didn’t take long for this to filter through, and now a certain class of patient (including illegals) EXPECT the best care for free. Obamacare seeks to cement this entitlement and it is going to, let me put this gently, KILL a lot of people.

I am not going to be participating in this dance, but I have an easy choice... I have an out now, for real, and I’m taking it. **  I’m taking a pay cut, but taking a lifestyle raise. I will be trading money for sleep and family. I can’t wait. I believe that once my colleagues get to a financial position where this choice is open to them, that most will make the same one that I have, that ‘Cat has, and that an increasing number of Emergency Physicians have. If you don’t believe me simply google “Emergency Department Closures” or “physician shortage” and see what you get.

The ultimate result of the dunderheaded and Machiavellian EMTALA/Obamacare power play will be, unfortunately, to hurt the very folks it was alleged to help, for the rich will always get good care, but when there are too few doctors to go around, the ER will be where poor people and illegals go to die. Through the looking glass, down the rabbit hole.


* For those of you thinking that medical school should therefore be ‘free’, please stop reading and go throw yourselves from a building more than 45 feet above pavement.
** I am going to work a 9-5 job which involve a little medicine and a lot of handshaking. More when I start the job.

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National Health Care part II (for Hannah)

This was supposed to be a thread within the National Health Care post....but I guess it was too long and it wouldn't post. So I had to make a separate post.

Hannah: This initially short response turned into a 4 hour tome because of my passion for the issues raised here. I'd appreciate your attention to consider my points and examples. This isn't theory for me. I live it every day. It's doubtful any of the politicians promising "Universal Healthcare" (Democrat or Republican) have spent more than 5 minutes in an ER for anything more than a photo-op.

Thank you for defining yourself as a non-conservative and thus giving me an opportunity to discuss this with you (hopefully in a rational way)!

I (and most if not all of the other bloggers here) want medicine fixed too, we just have different methods in mind to achieve a solution. Read our posts....we're all very unhappy right now (except for Etotheipi who blissfully dissects stuff and avoids the ED)
Most Libertarians and Conservatives aren't mean or nasty. Unlike what you'll hear Hillary or Obama say, we don't want to let people die in the streets....unless maybe it's Hillary, but I digress.

Like 911 has repeatedly said...we believe there must be some level of personal responsibility to health care. If not, it's a waste of time to even treat! Even well insured patients who won't take personal responsibility don't keep their doctor appointments, don't check their blood sugar, etc are a source of ire for docs, and a drain on our system.

We DO see tons of lazy, stupid, entitled, and irresponsible people in the ED. Those folks make up the majority of our problem. But by NO means do I or any of the other bloggers here think EVERY uninsured person is lazy. I'd be willing to bet that you fit NONE of my above adjectives. You read about us bitching about the lazy ones because they drive us so crazy.

Don't feel like we're piling on you here, we're frustrated because people outside of our industry see rising health care costs and insist that the Government fix it. No, No, No...the Government is largely responsible for breaking it! Remove some of the regulations, narrowly define EMTALA, control illegal immigration, give us some tort reform, and the private sector will take care of the problem. Competition drives costs down and improves services. In my town of less than 100K people, we have 9 CT scanners (including 2 of the latest generation models), 5 MRI machines, and a PET scanner...all because of competition between 3 hospitals and several clinics.

Most of the bloggers here work in the health care industry and we see what the tremendous level of Government involvement has done thus far....everything is worse now than it was 15 years ago. "Universal Health Care" doesn't scare me because of the financial perspective (hell, I might even make more....at least at first).

It scares me because we have one of the finest health care systems in the world. Why? Because it's based on free market capitalism. We don't want socialized medicine as providers, and I assure you that you don't want it as a health care consumer.

I could pull out lots of examples, but let's use a common one: Not a day goes by that I don't see a patient with rotten teeth in the ER for a toothache. I have NOTHING against helping the poor....in fact I don't think we help them enough.

We should work harder and spend more to get them back on their feet and back as productive members of society. With a definite END in site to their benefits. NOT the current lifetime of Medicaid as long as they don't work over 25 to 30 hours a week or make above the poverty level. (I'm not talking about folks with mental retardation or other true disabilities...so please don't go there with an attempted rebuttal).

I can give you HUNDREDS of examples for every condition you can think of from "fibromyalgia" (whatever the fuck that is) to chronic pelvic pain, to migrane headaches, to real diseases like congestive heart failure and diabetes.

But back to my toothache example, in almost every single one of these cases (and the other ER docs on here will back me up), the person is wearing very nice clothes, has a late model cell phone, fancy tennis shoes, manicured nails and expensive hair styles - (if female), and he or she usually reeks of tobacco. In other words they have plenty of cash for what they WANT and think is worthy of spending their cash on.

"When did your tooth start hurting?" I ask. The responses are usually weeks to years. "Have you called a dentist to schedule an appointment?" I ask. "No, they're too expensive" or "I didn't have the money to see one" are the usual replies.

It's a matter of priorities and taking responsibility for your own healthcare needs. This is where Libs and Conservative/Libertarian folks part company.

Hannah, I'd be willing to bet that you worry about paying your bills whether to the dentist, PCP, or, ER. Thank you. I'll bet you even AVOID going when you need to because of the cost, and I'll bet you chose the least expensive alternatives available(like a direct care instead of an ED). You're almost certainly NOT the problem or the source of our griping! It's the people who expect all care for free, choose when they're gonna come in (usually at 3am "don't you have a dentist here?", and want it fixed NOW, for free. These people are the problem whether we're talking toothaches, snotty noses, coughs, vomiting for weeks (always with normal lab studies...amazing), severe chronic back pain, exacerbation of "fibromyalgia", twice weekly migrane headaches only relieved with IV Demerol, knee/arm/shoulder/ pain for months etc, etc, etc.

Go sit in you local county ER as a volunteer on a couple of Friday or Saturday nights and see WHO we're talking about. It'll rock your world and change your perspective!

Usually, I'm dealing with a heart attack, a car crash patient, a stroke, and all other kinds of actual emergencies...but these non-emergent freebie people are almost always the most rude, threatening, unappreciative and demanding. ("I'm gonna call my lawyer if you don't hurry up and see me".....funny how once I hear that, their chart always leapfrogs to the bottom of the pile or occasionally gets "lost" behind the desk or into the paper shredder).

Again, the other ER docs will likely back me up on my perception.

As I said in another post when a guy complained that his ER doctor bill was almost $1,000...You've gotta understand that your charges are so expensive because you're paying the bill for all of these other people. Why?...Must be greedy doctors, right? Wrong. It's largely because of a law passed by liberals. (It started here in Texas I'm sad to say by liberals and spread nationwide to become EMTALA). It says they get evaluations regardless of their ability to pay. Of the $1,000 the poor got charged, I'd see about $65 to $70 (out of which I get to spend about $20K a year for malpractice coverage though I've never been sued).
I make no more now than I did 8 years ago and I DEFINITELY work a lot harder. I probably won't make any more 10 years from now. (But my hospital admistrator will, and your political representatives will) .

While in any other business or profession, you'd expect to make more the longer and harder you work, it ain't workin' out that way for most of us in ER Medicine. No other job in the world requires over a decade of training and then expects people to perform a significant part of their work for free. AND risk a lawsuit if the patient is unhappy.

Even the lady I buy donuts from for my nurses spent a single day learning to make the donuts...but she doesn't give them away (and no one expects her to). Health care costs have gone up in the past 10 years, but I make the same....why is that? Your answers are mostly above.

The intent of the EMTALA law wasn't to turn the ER into the cesspool that it has become, but that's what happened. It was a well intentioned attempt to keep hospitals from refusing to treat truly emergent patients. But due to typical liberal "feel-good" legislation...no one ever considered the unintended consensequences of such a law. Now that we see the mess it's created (not to mention the entire culture and mindset it's spawned), it's failures are seen by the Left as a result of the medical establishment and the "Rich Doctors"...BULLSHIT!

You and I don't disagree. I believe every U.S. Citizen should have access to basic healthcare. And I believe non-Citizens can pay for it. But NEWSFLASH...ER Docs aren't trained to be primary care doctors! (I tell patients..."yes, I am a doctor, but I don't specialize in your problem. I take care of EMERGENCIES for a living. It's like taking your broken car to a refigerator mechanic. You'd never do that even though both are mechanics, you know that they're trained for different things. You must see a PCP for your xxxxxx".

I see a number of ways to help the problems without taxing the crap out of everyone or breaking down our current system into a socialist nightmare.Since fewer than 20% of the US population has no health coverage, (based on the latest numbers from 2005) why oh why do we want to screw up health care for the other 80%? I know, it's politically sexy to promise this. It makes the various Presidential candidates seem like they care....NO ONE should be this gullible, yet sadly many Americans are.

First, we definitely need more patient education! Any solution has to be accompanied by an intensive patient education campaign. It's not unusual (saw it just last night) for a parent to bring a baby to the ER because of ONE episode of spitting up!?! Baby was FINE when I saw him. Why you ask would they pack up and come in for ONE episode of spitting up in a 9 month old? BECAUSE IT'S FREE TO THEM.

Here are three quick suggestions:

1) Let docs DEDUCT the bad debt from their taxes encountered by non-paying patients. Then there's some incentive and no less penalty for seeing these folks. This would have to be associated with malpractice or tort reform nationwide (see next issue). But when you get a doc's bill, understand that it's mostly for their knowledge. We spend 11 to 16 years training to be doctors. There are plenty of bright young people (my daughter among them) that are planning to avoid medicine all-together if this socialized crap passes. Unless there's some reasonable financial reward for their many years of study and effort. College, Med School, and Residency are TOUGH! Very few people are gonna do it to be rewarded with socialistic medicine hassles and shitty incomes.

2) TORT REFORM! You'll NEVER get this passed by Democrats who are largely funded by trial lawyers and ambulance chasers. But in Texas, since it's passage in 2002, we've seen frivolous malpractice cases decline and insurance rates decrease. We went from 2 companies willing to write ER Docs policies to 11 companies! This is the result of competition in the marketplace. Despite the spin the left tries to put on the law, a victim of malpractice is still rewarded ACTUAL damages...no matter the costs. The cap was placed at $250K PER OCCURANCE for punative damages only.

3) You can already get student loans forgiven if you go to work in "underserved" areas for a certain number of years. The average med student graduates owing over $125,000 in loans. Set up county run public health care clinics for primary medical issues (the same for dentistry). Work a deal where you pay these docs a reasonable income and forgive their loans if they remain for 3 to 5 years.

Those are easy and fairly immediate solutions to the lack of access problem. The ER just can't continue to absorb these people (plus, I SUCK at primary care...that's not what I do for a living). I'm not managing your "fibromyalgia" since I don't believe in it, and I'm not managing your chronic back pain, either. I'm not an expert in chronic hypertension control or diabetic sugar control.

I'm a "safety net" with some big holes in it.

Thank you for reading.

85


ADDENDUM: OUR FRIENDS AT 'THE HAPPY HOSPITALIST' ECHO, ECHO, ECHO...

Reasons I'm Leaving Emergency Medicine (number 8)

The Business of Medicine:

If there's one thing that flips me out within the first two sentences of a discussion it's talk about our customers. I have beaten this one to death and will simply link to some older posts here and following.

Medicine, particularly Emergency Medicine, IS a business in that it runs on money, but it is in terrible trouble because a whole bunch of folks, mostly politicians, pretend it's a unique business not susceptible to silly things like supply and demand.

As a result of unfunded give-aways and mandates medicine is much more like a mob racket than a business.

Where is our money coming from, and how can we sustain ourselves doing what we do now? The answer is by stealing. All of us in this racket steal from folks with money to pay for those without. When it's done officially this is called taxation, but this kind of stealing is called compassion.

For God's sake at least call it what it is. We started losing this battle with a little teency-tincy program called medicare/medicaid that was only for the most down-and-out and most pitifully poor and debilitated. Now we extend these benefits to illegal aliens, criminals, folks with bogus diseases, and, basically, anyone who shows up at an ER.

In my town it is well known that for misdemeanor offenses and minor felonies that if you develop angina incarcerans that you will only be cited, and the cops will dump you in the ER to be released on your own recognizance after we determine the crack you smoked will not kill you this time (the police can't pay the bill either).

The ER has become very efficient at 'moving the meat'... winnowing through haystacks of primary care, medicine, and psychiatric patients to find the 'needle' patient who has heart disease, a stroke, or new onset schizophrenia.

In the meantime between the 'free' ambulance ride and the 'free' care mandated by EMTALA we lose hundreds of millions, if not billions of dollars doing this, and the there is no disincentive for the abusers. These costs are transferred directly to on-call specialists and the hospital who then transfer the costs to paying patients (and doctors quit or go completely private and otherwise solid citizens despair). Never mind that this "free care" is not tax-deductible, nor is it protected from litigation... not even capped.

If you sell cars it would go like this...

Government (to car dealer):

Ahmed here is new to the country, poor, and needs a car to get to work, give him one for free. Do the maintenance for free, and, if you give him a car with brakes that don't work and he gets in a crash he gets your house. No, you can't claim it as a loss you just need to "figure it out". And oh by the way, his wife needs one too. Pony up dude.

It is unsustainable idiocy and, in the end, hurts the very people it is designed to protect. Don't believe me about doctors quitting? Just within the linked blogs on my site my colleague at "Fingers and Tubes in Every Orifice" quit a year ago. I'm quitting in 8 weeks. Schrodinger's cat is quitting in 8 weeks. Two other friends in ER in another state are quitting (and just two years out of residency). And our impromptu poll is interesting, is it not?

At my hospital within the last four years we have lost three urologists to EMTALA, one general surgeon, and four of our six orthopedists in town are about to go private. We have no neurosurgeon, no pediatric surgeon, no plastic surgeon, no psychiatrist, no endocrinologist, no rheumatologist, we have neurology ten days out of the month, we have ENT fifteen days out of the month, and we have ophthalmology 24 days out of the month. We can not recruit new doctors or nurses. We are a town of 400,000 and we are the only game in town.

Private ERs are opening and insurance only (no medicare) hospitals are opening and doing well. Charity hospitals, our old stop-gap, are gone for the most part. Ten years from now without doing anything we will look just like Canada or England. That may make you happy but it should scare the shit out of you.

So asking me to improve my "customer service" (my Press-Gainey scores), and to get ready for JCHAO is a lot like asking me to put the cover sheet on my TPS reports. Business? Thievery.

What is the Number? (MDOD Physician Poll)

One of the easily anticipated consequences of EMTALA + customer satisfaction surveys in the Emergency Department is to create an environment where the patient is always right.

Yes, I meant to say that... for surely they are not customers like a pizza parlor or car dealership has customers.... for those customers can easily go to the next pizza parlor or car lot and have some idea of what a fair price would be and what good service would be.

Now, given that pizzas and cars are too important to be left to the free market, I don't know why pizza parlor operators and car lot owners have not had an EMTALA-like law crammed down their throats, but they haven't... and last time I looked the pizza AND car industries were doing quite well (with the notable exception of GM), and, to boot, most reserve the right to refuse service to anyone.

So here's the question docs.... What percentage of patient complaints should an ER physician get. There has to be a number UNDER which you are not practicing good medicine because you are not saying "NO". I have my own ideas what this number is, but what say you?


The patient is not always right, and we do not have customers.

EMTALAEMTALAEMTALAEMTALA Duh.

Please read this.

So here's a cherry example of what happens when the government sees a problem in the private sector and tries to fix it by passing a law. I witnessed this in action in my military days. One summer, when the medical students on a military scholarship were rotating through various hospitals in the military system, a student was killed in a traffic accident en route to their clerkship. The military then decided that no medical students would be allowed to drive to their summer clerkships. Good solution, wouldn't want anything dangerous to happen to someone in the military. Cars are dangerous.

So did the kid need his lip fixed? Maybe. That's really not the point. I don't have pictures and I wasn't there so I can't comment, but choosing NOT to close a dog bit to the lip or to opt for delayed closure is at least reasonable. The teaching changes every few years and I will close most dog bites, but not all.

Both our national colleges fell for this hook, line, and sinker. What a bunch of pussies. How can you say that this boy didn't need treatment immediately? Here's how... This kind of repair, evidently done by a plastic surgeon, would be impossible outside a large city as large cities are the only places where you can get one 'on call'. You might get lucky and be at a hospital with OMFS (oral-maxillofacial surgery) or a game ENT, but right from the get go this is a hot potato of liability for any doc that chooses to close this wound. Do you want to suture his lip with an angry mom watching your every move knowing that the wound, by definition, has a high likelihood of infection? I don't. So not everyone in the country would have this procedure available at the drop of a hat and that's not fair. What to do... What to do?? I got it! Let's pass a law guaranteeing access to a plastic surgeon 24/7 anywhere in the US. Awesome! Problem solved. Next? This governing thing is so easy.

I can see it now. An angry mom, justifiably so (but angry at the wrong person), not getting what she wants that very instant for her child. An angry mom convinced she and her son are the victim of the 'wallet biopsy'. In fact, I would wager a lot of money that had the mom NOT been a person of color that she would not have succeeded at the second hospital. If the lip was torn to shreds it would be beyond an ER doc to fix it properly and if it was torn to shreds there is no 'emergency' here... the child was referred for definitive closure at a later date. So what's the problem? The appearance of an EMTALA violation.

EMTALA, the law that killed American medicine. The law which, if it were applied to say, grocers, would read, "Thou shalt give food away to anyone in your store who claims to be hungry or you will be fined and may lose your license to sell groceries and if we are really mad we'll throw in a lawsuit too."

The law which the average Joe on the street has finally figured out. The law that gave us this bit of ridiculousness. The law that killed my profession by making it an endless parade of entitled (mostly) faux-misery. The law that makes otherwise apparently very bright people say something like the following...

...ACEP's Dr. Gardner said emergency physicians must consider not only legal obligations but also moral and ethical responsibilities to the patient. "Every action we take as emergency physicians should pass the 'Aunt Betsy' test: 'Is it good enough for your Aunt Betsy?' " she said. "If not, I don't think it's something emergency physicians should be doing."

Or this from a physician whose other job is to outlaw guns in every home and who oversees the chaos and failure at Atlanta's Grady hospital...

The danger is that patients without private insurance often do not have access to care elsewhere.

"If we don't see them in the emergency room, they will not get the care they need, and some of them will come back much sicker," said Dr. Kellermann, professor and associate dean for health policy at Emory University School of Medicine in Atlanta, Georgia. "Most of my colleagues are unwilling to not treat [low-acuity] ED patients if they do not have reasonable assurance that the patients have someplace appropriate to go."

Okay, I'll play with your hypotheticals Drs Gardner and Kellerman. My Aunt Betsy is a non-compliant diabetic, alcoholic, child abuser who films and distributes child pornography and just took 8 hits on the crack pipe. She was bitten by one of her thirty attack dogs which she does not properly keep, and her lip is 'tore up'. The family can't wait for her to die. She has cost us all countless hours of misery and countless dollars hiring lawyers to keep her sorry ass out of jail. So yes, it is "good enough for Aunt Betsy".

As to Dr. Kellerman, well, I sure would like to save the world but right now I'm just trying to make it through another year in a high acuity ER with 30% payors, 30% admissions, and 50% 'shoulda gone somewhere else and didn't need the ambulance and wont pay a dime.'

But back to Aunt Betsy... Fifty Al Qaeda fighters, wounded in battle with the USMC, somehow manage to get to your ER. All require surgery. What do you do? Ten escaped convicts who just murdered your security guards? Charles Manson with a heart attack? Hitler? Satan? I am comforted that I now have an answer and will simply think of "Aunt Betsy." There's a fine line between clever and stupid.

Practicing Emergency Medicine as Dr. Gardner would have us practice also would lead to the following (as long as we are throwing out hypotheticals). People will get the message that there's no downside to walking around uninsured. There's no need to budget for it. All you have to do is call 911 or go to the ER. If you don't get what you want then threaten or scream and ultimately you might just need to go down the street to the next ER. "The government" is paying for it so it's free. Also, if you feel you are were treated poorly (with the wealth of medical knowledge that you have acquired by studying in your off-hours) then you can call one of those lawyers on those billboards and sue. You might just hit the jackpot. Then, ER physicians, castrated, will quit mid-career and leave a gaping hole in coverage across the United States, and hospitals will close or 'reorganize' so as to avoid the money pit. Oh wait, that's what's happening now.