Schizo

Evidently there is a theory, probably way out of favor by now, that schizophrenia may be caused by a 'double bind' existence... no clear choice... stay with dad who beats you or mom who is always drunk and out of the house. I don't know, makes some sense to me.

So today I took care of a typical happy little kid whose mom was terrified that he had appendicitis because a neighbor's child had it recently and it had almost been missed and the child almost died. Of course, I got all this history through a translator. Benign exam, I held my breath and addressed the mom's concerns. I ordered labs. Kid looked like a million dollars. I have become numb to it all and this seems to be a pretty good protection mechanism. The poor translator had to be here for four hours while the workup proceeded, and finally we had the scan results (ordered begrudgingly by me because the kid was anorectic and pointed to his epigastrium as the source of his pain... he spoke and understood English, but mom did not)... acute appendicitis. To the OR. Guess it's catchin'.

Now I have a patient that told me up front that he was coming to the ER because he 'can't afford a real doctor' and he has a complaint of twenty years of abdominal pain and also bad teeth. His girlfriend just left him and he's 'depressed' (according to his sister who has had depression herself for a long time) and can't I prescribe some antidepressants and antibiotics? She also wants to make sure he doesn't have cancer. I'm spending lots of your money on him.

Haldol, take me away.

Entitled or Amnestic?

It sure SEEMS like the entitlement mentality holds sway over a greater proportion of our population today than it did when I was in college. It SEEMS like the numbers back this up. It SEEMS like in just ten years that the percentage of patients I see in the ER who speak to me like a bastard child has increased. Am I right? I mean, I'm starting to sound like my dad so I'm a little less than convinced. Perhaps I am amnestic, forgetting the trials of our past, like Jimmy Carter for instance. Comments?

A Few Things...

Actual Patient Conversation

"Hello, I'm Dr. Panda. What brings you folks in to the Emergency Department."

"I think my baby has an ear infection."

"What does your pediatrician think about it?"

"I didn't call."

"Why not?"

"I only call the pediatrician for important things."


And Another...

"Excuse me, do you know when that jackass doctor is going to get around to see me?"

"I'm the Jackass Doctor. We're really busy today and I will get to you as soon as I possibly can."

"I've been here for two hours."

"Sorry, I've had some really sick patients today."

"Man..I could have just gone to Wal Mart and got some cold medicine."


One More...

(Very Pleasant Gentleman in a Hall Bed)

"You know what, I can see that you're really busy today. I'm really not that sick. I think I'll just go home and call my doctor in the morning."

Bear With Me

Sure, my first post on this blog was something of a diatribe, laden with cliches and an exercise in dead horse flagellation. That there was nothing original in the whole article has been established definitively by many of my critics. I beg your indulgence. I have not written much over the last year and I'm a little rusty. In my defense, I have well over 700 pages of content on my old blog and if you think it's easy coming up with something original to say in every article I invite you to try it.

On the other hand, some things just need to be repeated again and again, particularly anecdotal evidence to support the general consensus that American Medicine is an insane Goat Rodeo organized and directed by the rodeo clowns who ensure that it is as difficult and expensive to deliver care as it can possibly be. The paperwork burden alone is phenomenal and grows every year defying any kind of reason or common sense except the inexorable logic of a rapidly expanding state and federal bureaucracy that exists to perpetuate and amplify this kind of thing in the circle jerk that we know as public service.

I am also amazed that, in exchange for the right to comment on American Goat Rodeodery, I must provide intricate solutions to its problems. In fact, the solutions are as obvious as they are difficult to implement and there is no amount of policy wonkery or 2000-page Health Care Bills That Nobody Read that will change the basic facts that we are ridiculously over-doctored, over-litigated, over-regulated, and over entitled. Or that most of the money spent on medical care is wasted and buys services that are at best horrifically redundant but mostly just unnecessary. Medical care, something that most people don't need much of most of the time has become the bloated tail wagging the corpulent national dog and is both the cause of our economic decline and the blunt instrument to be used by government to extend its influence into every aspect of your life. We have gone insane in this country harboring as we do a pathological fear that somebody, somewhere, somehow might be expected to pay for his own routine medical care.

Why, it might cut into his cigarette money.

It is this insanity that serves as a permanent obstacle to common sense things like meaningful medical malpractice reforms, ending the practice of futile care, holding people accountable for lifestyle decisions, and making it just a little more difficult for a 25-year-old methadone addict to collect disability.

Medical School Debt

I never said my debt was unmanageable. I just commented that the month between the end of residency and my first real paycheck was a difficult one. I'm actually paid pretty well, a lot more than I thought I would be making, and on that point I have no complaints. I imagine the economic outlook for Emergency Physicians will continue to improve as the wonder that is Obamacare unfolds on an unsuspecting public who will have trouble finding primary care doctors who are still in business. Hell, Emergency Departments are already swamped. I see between thirty and forty patients in a twelve hour shift and while not all of them are minor complaints, the vast majority are and when you take out the patients who are lazy, stupid, and irresponsible, a good portion of those are people who simply could not get a timely appointment with their own doctor.

I'm a special case in regard to debt anyway as I was a non-traditional medical student and resident. Generally, if you follow the normal path into medicine (college to medical school to residency to practice) your debt is very reasonable compared to your income and you would be stupid to ask the government to pay your way, thereby ensuring they have a first dibs on your ass at all times. The hardships of medical school debt, for most doctors, is something of a myth.

Save Yourselves and Prosper

When our colleagues want to criticize our approach to medicine in the wild, wild west, they call us "cowboys". So be it. And guess what? You too can take to the road with your skills and wits only and be paid what you are worth. You can be kinda like this guy above... instead of a gun you will carry a telephone. The telephone will be a deadly weapon against your consultants. You can not, however, use it to beat your waste-of-time-and-money patients (or you will be arrested).

And there's another funny thing... Our colleagues, especially on the surgical side, can not do this. They are tied to their hospitals, they can't operate, at least to do the big cases, without hospital privileges. I feel bad for them, because this can be held over their heads. Same with folks establishing a practice in a town associated with a hospital, or folks working solely in a hospital.

Locums companies are now offering me almost twice what I make working for my group to travel, be put up in a nice hotel, and cover the uncovered military ER in Bumfoodle USA, or the VA "ER" in East Tiddely-fa. Seems to me that rather than go through a locums company that I can just put send out a few letters, offer my services as a hired gun, and cut out the locums company making $50 an hour off my back. Then again, I am burned out and leaving and wouldn't do it for the money, but YOU guys, especially you medical students and residents, think seriously about this.

You may have to work out in a group for a couple of years, but after that, after you get your sea-legs, why send thousands a dollars a month to your group director(s) or your hospital? Become a traveler, an itinerant doc, a gunslinger. Go stay at the beach on someone else's dime, go to the mountains the same way. Go make twice as much and when you find a crappy hospital walk away and go to the next one. You may just keep your sanity AND be able to retire a lot sooner. Everyone else sees you as a commodity, why not behave accordingly?

Use the logic of the professional athlete, for it is sound. You have an increasingly unique and valuable skill... make your best deal. You only have a few years at it, ten on average (per our own college's statistics), so protect you and yours and get paid yo!

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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15% off scrub tops with code "top_sale"
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Lofty's 80-80 Rule

According to a Pew Hispanic Center report, in 2005, 57% of illegal immigrants were from Mexico, 24% were from other Latin American countries, primarily from Central America, 9% were from Asia, 6% were from Europe, and 4% were from the rest of the world.

So, if 80% of illegal immigrants LOOK latino because they ARE latino, and if 80% of people questioned about their citizenship status in Arizona (AFTER BREAKING THE LAW) are latino, then that's not profiling, right? RIGHT? That's perfect fucking common sense and perfect math.

Idiots.

My Favorite Year

I am an Emergency Physician and every day I go down the rabbit hole into the insane world of American Medicine. The waiting room is always full and despite the bogus statistics promulgated by ACEP to justify our existence, the majority of presenting complaints are nowhere close to being emergencies. In fact, most of what I see requires no organized medical intervention of any kind. Your toddler with a fever, for example, would do just as well with a little Wal Mart Ibuprofen as he does after a three-hour wait and a few hundred bucks of the taxpayer's money. And no, I'm not going to run lab tests and shoot a chest xray on a kid who is running around the room stuffing Cheetos into his mouth. Your rash? I can't even see it and if I could, so what? People get rashes. Same with your headache. People get headaches. We take a Tylenol. It's not meningitis. You're not bleeding in your skull. Your vitals are normal and the imperious way you hold up one finger to keep me from interrupting your phone conversation speaks volumes. I'm not giving you a shot and Motrin works for everybody despite what you tell me. It's a chemistry thing.


I am an Emergency Physician and this is not the Golden Age of Medicine lovingly described by the older doctors whose shoes I am not worthy to fill. You had your Virchow's Triad and your Grey Cullen sign but I am not so fortunate. People used to wait to go to the doctor and when you saw them they had a distinct constellation of symptoms around which you could wrap an eponym to demonstrate your genius. Today most of my patients present with a little bit of pain here or some dull ache there or some vague constipation a week ago and "I've been feeling some chills." I dare not ask the question-of-doom because the patient will get a faraway look and say, "You know, come to think of it I did have a little chest pain."


I am an Emergency Physician and everybody lies to me. There was a time when going to the Emergency Department was a big event in life. Even going to your own doctor was usually reserved for real but less urgent problems. Today everything is "ten-out-of-ten" on the pain scale. Or twelve. But you were asleep when I walked in...or you were polishing off a hamburger and fries. Can your pain really be that intense and more importantly, does it really need powerful narcotics? Are you really here for pelvic pain or do you really just want a pregnancy test or a picture of your seven week fetus to show the babydaddy and your momma told you what to say to the stupid doctor? Is this just a lame story to get a work note? Your next fix? Thank god most drug-seekers aren't towering intellectuals because they could, after an hour of Internet research, construct an airtight story complete with sham exam findings that would be hard for any doctor to defeat.


I am an Emergency Physician and I work in an Emergency Department that sits astride the major trade routes trafficking in the elderly and whose supporting hospital was strategically placed to command this trade and its rich plunder; bountiful cargoes of stable but chronic disease, vague complaints, and loneliness that fill our coffers with splendid treasures to rival the hordes of ancient kings. Or I dump hundreds of thousands of dollars into futile care. How I plunder the federal galleon like a modern-day freebooter, raking in the Medicare doubloons to extend the futile quasi-life of the living dead for whom death would be merciful!

I am Panda Bear. You may know me as a once prolific blogger who sort of faded away after he finished residency last June. I've been busy. Inexplicably I am working more hours than I did as a resident. I'm less stressed but the reality is that medical school and residency wiped me out financially and I have no choice. The scariest moment of my medical career was the day before I got my first real paycheck when I realized that my entire net worth was the half-gallon of gas in the tank of my ten-year-old car. Sure, I got a nice check the next day and began to staunch the financial hemorrhage but it's not pleasant to be 45 with no money, no savings, no investments, no credit, and a terrifying debt burden the bill for which had now come due. I tried not to think about it but if something had happened to me my family would have starved.

Naturally I'm divorced even though nine years ago my ex-wife and I would have laughed if you had said it could happen to us. Residency was just too much for my most excellent ex-wife who got tired of me being tired and of the residency program, the patients, and the hospital stealing the best parts of me leaving nothing but exhaustion and bitterness at home.

Welcome to MDOD, PandaBearMD

He's BAAACCKKK and he's here. See above.

I Make a Billion Dollars

They say you know you are dealing with an Axis 2 personality disorder patient if, within thirty seconds of being in their presence, you either want to stab them in the eye with a pencil, OR (for florid Axis 2 patients) you want to stab yourself in the eye with a pencil. Last night, the pencil was pulled forcibly from my hand.

You know who you are girl. And just for the record, doctors do not make 'a billion dollars' a year and your complaints, vital signs, and exam were not indicative of either a need for haste or narcotics. Also, the 'insurance' you have is off the backs of your neighbors and I didn't hear you thank them.

One day you will get your comeuppance for storming out of the ER while yelling at me, waking the drunks, dropping the "I'm going to sue you" bomb (go ahead), and accusing me of being more evil than George Bush. I know you will feel better as soon as you beat your simpering boyfriend, but you and your entitled, ignorant, asswipe clones have crushed my spirit and made medicine as fun as the inquisition, and as challenging as getting a PhD modern liberal thought.

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15% off scrub tops with code "top_sale"

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I Was There

Over the past twenty years our ability to treat heart attacks, particularly STEMI heart attacks (ST segment eleveation myocardial infarction), has undergone a revolutionary change for the better.

The other night I was on a shift and a call from Booneyville EMS came in declaring that their patient, at that moment, was having a STEMI. They didn't have the capability of sending us the EKG but, per recent changes in hospital policy (oh it hurts me to admit they did something right), we were to activate the cath lab team and get the cardiologist in.

It's a strange position to be in... On the one hand we hope the EMS guys are wrong, for the patient's sake, on the other hand, we do not want to have 'cried wolf'. Well, this guy was the real deal. Part of his heart was dying.

He made it from our door to the cath lab and had the blocked artery opened in 24 minutes. That's pretty damned good. I mostly just watched and that was fine with me. The patient did well.

Qualifications for Becoming Physician to be Dropped

Dear Leader has nominated a woman with no previous judicial experience for the Supreme Court. In spite of how this sounds it is not without precedent.

It really is quite brilliant... In a few years when there are not enough physicians (even in large cities) Dear Leader may simply pronounce people "Doctor". VOILA! Problem solved... everyone has a doctor.

There will still be requirements however, one must be female, well schooled in gender and race politics, and have accomplished absolutely nothing that can not be tied to one's gender-racial-sexual identity profile.

Welcome to Rome.

Pop! Ouch! Get the Translator (the word is 'lengüeta')

This patient was very nice and quite easy to work with. He was thankful and did well, but it was all in Spanish. I do medical Spanish, but how do you ask if there is a barb in the nail that is buried to the hub in your lower leg?

Now notice the nail on the X Ray above... nail-gun injuries used to be so ho-hum, but the folks who make the nails figured out that if you put barbs in them that they will not back out of the wood over time. Problem is, they don't back out of bone too well either. No matter! A little propofol and a mighty pull with some vice-grips and we were done, but, this muchacho will always have a small piece of barb in his tibia. A reminder of the day he said whatever 'oops' is in Spanish.

You, sir, are guilty of "organ profiling"

This will happen soon...very soon...in a hospital near you. Or, at least in a hospital in places like California or Massachusetts.

A 40-year old fat white woman comes into the ER with intermittent right upper quadrant abdominal pain made worse by eating. An astute, well-trained surgeon is summoned and, using common sense, immediately suspects gallstones. An ultrasound confirms the presence of gallstones and the surgeon begins discussing plans for a cholecystectomy with the patient.

The charge nurse, sensing that the surgeon has not followed newly-adopted medical staff bylaw W4356.345,section 4A1a3 contacts hospital administration. The administrator, pulled away from his eighth ultra-important meeting of the day, ambles down to the ER and pulls the surgeon out of the room.

Administrator: Just what do you think you're doing?

Surgeon: What do you mean "what am I doing"? I am planning a cholecystectomy for my patient with gallstones.

Administrator: How do you know other intra-abdominal organs are not guilty...er, diseased as well? You, sir, are 'organ profiling'.

Surgeon: Well, douchebag, I figured that if it sounds like gallstones, looks like gallstones, and smells like gallstones, then it would be perfectly logical to call the gallbladder the offending organ and deal with it appropriately.

Administrator: You can no longer simply implicate an organ in our hospital without first evaluating all other potentially-involved organs. It's not fair. How do you know, for example, that the spleen is not the problem? Huh? The adminstration here has decided that we do not want to be called 'organists' or anything like that by various organizations that follow this stuff and put pressure on us. Just because the appendix and gallbladder have been shown in many clinical trials to be by far the the most common offenders causing acute abdominal pain, we believe each and every intra-abdominal organ should bear the burden of proving its innocence. There! I have been practicing saying that for months now. Boo yah!

Surgeon: The spleen, like an 80-year old white lady named Agnes driving around Arizona with her freshly-minted Arizona drivers license, is highly unlikely to be the cause of the problem. The gallbladder, let's call it Jose, on my ultrasound study just now, doesn't speak a fucking lick of English and was careening around this lady's abdomen in a beat-up Ford Pinto with seven other Mexicans crammed in the back seat. Common sense. Get it? Much more likely to be the cause of the problem here. I just can't, don't, and won't ever think like you fucking liberal fucks.

Administrator: You just also broke medical staff bylaw Q2346.661,section 2B4b3... professional conduct. You now have two citations and you will be required to meet with the quality committee of the hospital.

Surgeon: Fucking awesome. Who's on the quality committee these days?

Administrator: Well, there are two caucasians, two latinos - one from Guatemala and another from Mexico, an asian, a middle-easterner, and a european who recently emigrated here.

Surgeon: Wow, in our small rural town, that had to be hard to do.

Administrator: (Sighing)...It wasn't easy...I mean, they are all highly qualified people!! In fact, if you don't watch it, we have three surgeons from Mexico that are begging to move here and work in our general surgery department.

Surgeon: Perfect. Why the fuck aren't they here, then?

Administrator: We're having a hell of a time verifying their credentials.

Hot-Nanny State (part deux)

Please refer to previous eponymous post... I took this picture at an aquarium recently... it was posted outside the bathroom. Evidently bathrooms are more dangerous than sharks. Who knew? I'm so thankful for this information and am hoping Dear Leader can pass a law or something... maybe piggyback it (nice word choice, eh?) onto the anti-obesity bill.

The Hot Nanny State

I thought this was a stunning debate.

I see this busy body from time to time trying to push her anti-obesity agenda via legislation rather than education and persuasion. She believes that most Americans are incapable of making their own decisions, since most Americans do not fall into her definition of "thin".

While I occasionally agree with her message, I can not abide her methods.

She believes it is her right to force her opinion and agenda on everyone else through legislation.

She represents Liberalism in it's most pure and evil form. I'm not a Mike Gallagher fan, but I was cheering him as he took her to task for this idiotic proposal.