Less Carrot, No Stick: Life Working for the Man

I do not miss the ER.

Not a bit.

I do feel guilty from time to time for 'wasting my skills', but that, too, is fading I find it very ironic that I have ended up (in a sense) joining the enemy, simply to preserve my sanity. What I mean is that I now work for the government in a 'lifestyle' job when my great desire, from the end of medical school through my 'payback' time in the military and through residency was to become an excellent Emergency Physician and to practice my craft until they kicked me out of the hospital on a walker mumbling about how Zithromax is not really an antibiotic and how you should NEVER order a CBC.

My, my, my. I did, at least, achieve part of the goal. I was, and still am, an excellent Emergency Physician, but I am now almost phobic of hospitals. I won't go back unless I have to for money. The joy, if there ever was any (I think there was) is gone. It may still exist in ER practice but I think that if it does it's in isolated pockets or in Academia, but, for the record, I don't know any ER docs who feel this way. Most see themselves as drones or, perhaps, as performing a 'rear guard action' on a decimated battlefield.

This learned helplessness permeates much of medicine these days. Funny how, when lives are on the line, doctors and surgeons with MD or DO behind their names are beseeched and coerced and prodded into the fray, but when they talk about work conditions and reimbursement they are derided and spat upon.

At the same time charlatans like THIS COMPLETE MORON, a chiropractor (with an 'MD' mysteriously obtained from the University of the Caribbean Breezes) dispensing platitudes and snake oil, becomes rich and people love him. They line up to pay for his crap. The supplements market is booming. It's ALL shit. Big pharma is pilloried, but the people who market 'Raspberry Ketones' and 'Acai Berry' for 'weight loss', 'pro-biotics' and such, can laugh all the way to the bank and escape all manner of liability and regulation.

It's tempting to quote from "Atlas Shrugged" at this point but it's cliche and people think that because things are 'cliche' that they are necessarily false. Not many care about the plight of doctors, but they will.... they will care when they can't find one.

I will take no pleasure in their frustration, but I also will not be running back to help, and for that I think less of myself.

It's all stick and no carrot these days out in real-medicine land. Amazingly, I have found a 'medical' job that is mostly carrot, no stick whatsoever. Guess what? I LOVE it. I feel like I'm cheating. Compared to what I used to do, this is a lark.

I marvel at the surgeons and the ER docs who still man the barricades. They would make much more money with no liability by joining an aesthetic medicine practice and shooting people up with botox or simply hawking the snake oil that everyone does on 'Dr Oz' every day... What's that? It's already happening all over the place? Oh.

 *YAWN*

Offensive, Defensive Medicine

Case: 54 year old male with intermittent bulge to right inguinal area accompanied with intermittent,  sharp pain.

Class? Diagnosis? Treatment?

Class, how should this be diagnosed?

Reality. Internist has an idea... does KUB.... it may show a nephrolith. Internist prescribes antibiotics and steroids. Refers Urology.

Urology is not sure.... orders CT scan. CT does not show stone.

Patient sent home. Still in pain. A week later goes back to internist with picture of said 'bulge'. Internist has more clear idea. Refers to General Surgeon #1. General surgeon #1 thinks he knows. Refers to General surgeon #2 who disagrees with General surgeon #1 but agrees to operate anyway. Is surprised there is a CT Scan that has been done. Inquires as to results of scan. They are negative. He operates anyway and discovers, three weeks into course of illnesss...

Class?

And what did we learn?

EMTALA-Obama, Impacting Now....

Never know what you will run into on those two day drives to the beach... Here, we run into the future of American medicine. Cheers.

MDOD Douchebags of the Month

Hands down, douchebags of the month, and, as a kind reader points out, whilst 'practicing' medicine in the streets of Madison, these doctors are in violation of the following...

1. HIPAA.
Clearly no one is concerned about patient privacy here. And if I'm not mistaken, I can read a whole lot of identifying information on these 'notes'... Doctor's name, patient's name... And an ersatz mini-me castrati Michael Moore (but I repeat myself)... Really, did you go to med school dude? Because I see you much more as a bear-cub... if you know what I'm saying.... Not judging you, just pointing out the obvious... Don't shave your chest. And get used to being on your knees. Federal law violations here. I'm sure the Obama administration is all over it (no need for action on our parts).

2. TOFKAJCHAO Guidelines.
I mean, you could poop a sterling-silver turd that smelled like roses and cured HIV and you would still run afoul of these.Clearly there is food (and or herbal supplements) in the patient care areas here, and even though lots of marijuana is being smoked (which is completely cool and all)... somewhere here, tobacco is being smoked, and that's a clear whatchamacallit violation.

3. The smell test. Smells like 8th grade, passive aggressive bullshit. Michael Moore look-alike in video, ergo, is, in fact, 8th grade, passive-aggressive bullshit. Besides, if any of these 'patients' had been truly ill, you would have done what you always do.... you would have sent them to the ER.

4.The "Out and Proud" sensibilities of the United States of College Campuses of the Western World. Clearly the two chick doctors are lovers. Clearly the female teachers, every single one of them, are rug-munchers. The problem is that we don't even get to see them kiss, and their unshaven axillae are not flaunted, nor are they carrying a 'we hate penises' sign. I have no doubt they are in the Family Practice residency, which, to be fair, is quite demanding compared to becoming a teacher (though both eventually pay about the same), and they are going the extra mile to be trained in the fine art of dilation and curettage so as to limit the impact of overpopulation on mother-Gaia.

5. American sensibilities. Contrary to what Al Gore and Nancy Pelosi say, these exist, and are definable. Challenge... Go show this video in your local pub/ pool hall... see what reaction you get. You can ignore it or criticize it, but it's there. What you get there is what you would get everywhere except Portland, Seattle, San Francisco, NYC, Boston, and certain very special sections of Atlanta.

America! Support your teachers! Say, how are those kid's test scores doing? How is that public education these days? And hey, Dr. Shropshire and colleagues... you guys are a really bad joke. You are lying for the mob bosses and you didn't even get paid. Snoop Dog is frowning. Straight up.

The Good Old Days of American Medicine

The 'good old days' for doctors in America were the seventies. But let's talk about the 'good old days' for patients in America. They are right now and they are about to end. 

The good old days for patients have been at the expense of American doctors and nurses and paramedics for thirty years now, and because of EMTALA, Medicare, and gutless politicians and physicians. Group politics, super. See ya later individuality and achievement.

After Obama 'fixes' medicine my life will be easier and I will make more money for less work and with capped liability to boot! I will take some pleasure in pointing this out to all of you muddle headed liberal do-gooders and earth mothers out there, but not too much, because I will pull out a lot more 'pronouncment of death' forms. These patient encounters are easy and there's no risk and I get paid, so cool. You just have to make sure the patient is really dead, and this is only occasionally difficult. Here's a story about what will not happen anymore. 

You will not be an 80 year old smoker who has been struggling to breathe for two days and when you call 911 they will not get there right away. You will not be rushed to the hospital with lights and sirens blaring and you will not be thrust in front of me at 4am with a heart rate of 220, curiously the same as your systolic blood pressure, and I will not, then, do the following...

I will not run into the waiting room to find your family (after shouting out, IV, nitro drip, cardiazem 25 IV, morphine 4 IV, set up RSI, pacer pads!) to find out if you have a living will (you are too far gone to do more than scream and breathe).

Through their tears they will not tell me to 'do everything'.

I will not then run back into your room, pulling a few techs and nurses with me and do the following...

I will not give you 20mg of etomidate followed by 25mg of succinlycholine and slide an 8.0 tube into your trachea and hook you up to a vent.

I will not then push about 50mg of propofol on you before shocking you with 100 Joules of synchronized electricity to get you out of your atrial flutter with aberrancy, and will not rush you to the scanner to make sure you are not dissecting a thoracic aortic aneurysm or pushing against a massive pulmonary embolus.

I will not, after you come back from scan, have a brief moment to look in your eyes (as the propofol has been momentarily stopped), and apologize to you for intubating you (as it seemed like you didn't want me to do it, but I could not trust you (at the brink of death and without documentation) to make a good decision), and have you nod your head to me and try to thank me. 

I will not then send you to the ICU where, in spite of your continued smoking habit and lack of insurance or money, some of the finest critical care physicians I have known will, in all likelihood, succeed in getting you out of the hospital, back home, and comfortably smoking. They will lose money in the endeavor (and sleep and time away from family), but that's what they do now.

Instead, when you call 911, you will get a recording or be put on hold. If you make it past the call screener you will be rushed to the hospice where you will die in a haze of morphine. But, and here's the good part, it WILL be 'free' (and I will be free to take a nice nap on the overnight shift).