Monday, December 31, 2007
What I understand of the problems with primary care medicine has a lot to do with reimbursement and physician/ patient dissatisfaction. Considering that you have to deal with insurance company flunkies telling you that you’re not getting paid for some obscure reason or having a jackass with no medical education whatsoever pouring through years of medical files in order to request that you pay back the meager amount of money they considered adequate you can begin to understand why medical students throughout the US are avoiding primary care like the plague (now that’s a long sentence).
You should also be able to see that a doctor, burdened with these restrictions, increasingly diminishing returns for each patient, and the increasing cost of keeping a business running feels that they have to take care of patients in less than an optimal manner. Because of these feelings the physician becomes depressed, hates his profession and field, and ultimately leaves medicine earlier than planned.
Enter the new breed of physician. One who realizes that their time is not being spent wisely, that the insurance companies are forcing doctors to practice dangerously in order to make ends meet, or that docs all over are just opting out of medicine altogether. Some of these younger physicians, strained by the largest debt load ever encountered for their education, have decided to throw off the traditional shackles bestowed upon them by the myopic, arrogant, older generations and take their businesses back.
Retainer medicine is a form of this revolution. I remember seeing a report, long before medical school, about a doctor who performed house calls, saw ten or fewer patients a day, and was loved by his patients. It was surprising to learn that he required all his patients to pay a monthly premium, regardless of their usage, and was not considered “greedy” by those he treated. This was my first encounter with retainer medicine and it honestly made a lot of sense.
My understanding (faulty perhaps) is that a doctor, refusing to take insurance, asks his patients to pay a sum each month for services – regardless of whether the patient uses them or not - wherein the physician enters into a contract with them. The patient then has the ability to see the doctor when they need them and both parties can “fire” the other based on contractual agreement. This allows the physician to see fewer patients in their clinic, take as long as needed with each patient, and manage them to both the physician’s and (major plus) the patient's satisfaction.
You see, paying doctors per visit or procedure, as is done by most insurance companies, only forces primary care docs to see more patients each day – thus reducing their ability to care for their patients as they desire. It is hurtful to each, but the doctor suffers greatly from a feeling that they are betraying their patients in order to stay in business or meet every absurd insurance mandate. In effect they are at war between taking care of the people entrusting their care to them and the compensatory aspect that is absolutely mandatory to medical care. Concierge or retainer medicine reduces this because the patient pays the doctor, not their insurance, and they can treat the patient as they feel is necessary.
For primary care doctors, I feel that this a tremendous advantage to provide quality healthcare. At the same time it allows the patient to be more involved with their care, enables them to get a clearer understanding of their diseases and medications, and decreases feelings that they aren’t being cared for appropriately.
Some argue that there is an ethical disparity inherent in this program. Essentially their argument centers around the idea that the poorer populations will not be able to receive the same care and they feel that physicians who employ this form of practice are not allowing indigent populations access to healthcare. While I do understand this concern I don’t agree that the physician who decides to practice retainer medicine is being unethical. In fact, I feel they are more ethically motivated as they are now able to see and care for their patient based entirely on their training and medical expertise – not a medical officer hundreds of miles away who never sees patients.
I offered you two opposing view points earlier. Clearly I feel that Dr. Centor makes a valid observation and clearly illustrates reasons that this form of medicine allows for better health care. Given his years of experience, both personal and second hand, I feel he understands this concept more fully than the opposing view offered by Graham.
My appreciation of Graham is that of a medical student who, being a very bright and energetic individual, still completely buys into what’s being sold him by the old guard. While I’ve enjoyed some of his posts, I feel that Graham’s ideas are erroneous and posses a great deal of martyrdom to them that's bereft of responsibilities beyond them. There is absolutely no reason that a physician, regardless of their ability, should be required to care for people who can’t offer adequate compensation. I certainly applaud those who wish to help those who can’t pay, like Graham who states that he enjoys the prospect of EM because “seeing uninsured patients, [is] something I love about the field”. That’s great, but don’t force others to commit to providing less than stellar care to their patients just to see patients who can’t pay.
Saturday, December 29, 2007
Friday, December 28, 2007
Personally I have changing views on the subject. I used to believe that universal coverage was the best option – in effect, socialized medicine. Then I began reading about the Canadian and the NHS, their troubles, and realized that, even though their citizens are covered, they had harder times getting people to use the system correctly, providers throughout all spectrums were incredibly taxed to work "within" the system, and the outcomes were not much improved. Now I find myself less inclined towards universal healthcare, but struggling to find a plan that makes the most sense.
I do know that some of the political ideas of taxing physicians in order to help cover healthcare for the poor are just monstrously ignorant. Why should those who have to suffer direct losses from this patient population be forced to incur further decompensation simply because of their profession? Do we honestly expect doctors, the one profession that has little to no say in what they receive in reimbursement, to keep allowing insurance companies to decrease their payments precipitously while, at the same time begin taxing them for indigent populations for whom they've never received compensation? Would lawyers be so willing, I wonder, to take hits in the same respect as that offered by some of their colleagues? We all know the answer to that.
The idea of requisite health insurance seems more on the right track. We require people to have car insurance based on the degree of risk inherent with owning an automobile, so why not coverage for their health needs? Certainly people realize that at one time or another they’ll need the healthcare industry – either for minor ailments or severe conditions – and should be more capable of contributing towards their care. We are, as humans, inherently at risk each and every day.
Making people comprehend that they are responsible for covering their asses won’t be easy though. Massachussets has had significant backlash regarding their plan, some due to the significant cost of covering oneself, but a great deal from the parasitic nature of lower income and young populations. The idea of having to pay for something that one might never use has been routinely touted as a justifiable reason to avoid insurance mandates by those refusing to buy into the idea.
Despite the problems encountered by Massachussets, I feel its ideals are on the right track – shifting the responsibility onto those who are actually culpable for their actions and less on those who just have to deal with them. People are so eager to get the newest cell phone accessory, iPod, or fanciest TV regardless of their income level, but refuse to spend a few bucks each week towards their healthcare. Cigarettes continue to increase in price, yet the 1+ pack per day smoker doesn’t cut down on their habit, just their luxuries – like bills and responsible spending. I cannot count the numerous times I’ve seen someone with little to no insurance, complaining about the cost of their care, with a fancy cell phone, cigarettes, and a tricked out car who inevitably heads to the nearest fast food chain for lunch. It’s actually quite ironic to consider that the money spent on these gadgets and behaviors actually decreases one’s health (cancer, hearing loss, obesity, HTN, heart disease, etc.).
While I certainly don’t have the answer, I do feel socialized medicine is not the option that’s best for this country. As a 4th year medical student, it’s hard for me to even begin to understand the complexities of payments, billing, and the business of medical care, but I have been able to gather enough information to understand socialized medicine will only fail patients and providers together.
Wednesday, December 26, 2007
* Currently on Netflix account...will arrive someday.
Wife, Daughter and I went to see a movie as well. We saw The Water Horse which was an OK kids movie. Daughter really liked it, but it had some weird parts where I thought, that's a little dark for a kids movie...but whatever. It was nice though, to get out of the house in the evening. Wife feels that Christmas evening is always a bit anticlimactic, especially since we don't have anyone we spend it with, and getting out of the house shakes things up a bit.
So I wish that I could relax today, but here is a small list of the items that I realized I have to accomplish by the end of this week (or maybe next week):
1) Register my car. I would like to avoid getting a ticket for expired registration by one day - like what happened last year - on the way to my first day of a rotation. I can use $140 for better things than citations.
2) Take Daughter to her doctor’s office. She has been sick for over a week now and I can no longer convince myself that it’s simply a viral URI. Especially since she started to complain about her ear hurting and, upon inspection, I found it to be angry, bulging, and red looking. Amoxicillin, 60-80 mg/kg bid-tid for 5-7 days, if I remember correctly.
3) Order copies of my birth certificate and have it express mailed. I was looking at my driver’s license the other day and realized that after 8 years without having to obtain a new one this expires in 2 weeks. Unfortunately in this state I have to have my first renewal at the DMV (bastards!) and can’t just get a mail-it-in renewal. I also realized that I can’t dawdle on this since I have to fly to a few more interviews in January, with one being the 6th-8th, and an expired license will no longer be accepted as identification! Crap.
4) Hang out with freaks at the DMV…see above.
5) Find out if my next rotation starts next week or the week after. An e-mail sent out last week stated we were starting 5 days later than the scheduled by the school. I’ll be out of town on that date and don't want them cutting me out of the class if I don't show the first few days.
6) Plan Wife’s birthday party and get reservations for dinner.
So as you can see…a few things to do. Some more important than others, but all important.
Sunday, December 23, 2007
Saturday, December 22, 2007
Anyway, while out at other hospitals of various cities I’ve noticed a trend. You can always tell who the medical students, nurses, residents, and attendings are in the hospital. Just a little musing of mine, done at 3am while wishing to fall asleep on a very uncomfortable airport chair, but I thought that some of the non-med people might enjoy knowing how to tell the difference:
Medical Student: Of course, as if you required any other method to identify the future of medicine (laugh now…not so funny when they’re actually docs), the med studs are easily identified wearing the traditional, ass-enlarging, short white coats – stuffed full of books, tools of unimportance, and papers. They go about their business, eyeing everyone, but taking care to not be seen staring at particular individuals. If you needed anything more to identify the one person who has no authority over your care whatsoever we’d have to put an “I’m with stupid shirt” underneath the coat. The short coat has never and will never look good. On anyone. Often med students are seen as you are first admitted, getting the long and very detailed H&P in a haphazard fashion. They’re also seen very early in the morning and before dinner trying to get ready for rounds – you’ll most likely be sleeping when encountering them. After that you won’t see them unless a painful or humiliating procedure is about to be performed.
Nurse: This is a bit trickier, since this is more or less a gender and floor based observation, but they often wear the “fun scrubs”. You know the kind: cartoon animals, hobby oriented, bright, multi-colored garments that, for reasons unknown to me, are reserved for the nursing profession (like a white man trying to wear urban clothing, anyone else just doesn’t look right wearing these). I’ve seen nursing students wear mono-colored, dark apparel that suddenly transforms into the “fun nurse” scrubs upon graduating. I’ve also seen nurses who wore this festive garb (at least in their older pics) who, upon entering medical school, ditched them for the more restrictive patterns of hospital issued wear. There also seems to be a proclivity towards wearing scrubs with multiple pockets in them – like the front of the shirt or all down the side of the pants. Another trait inherent to the nurse is the ability to talk about more than just medicine. They have lives, are aware of the outside world, and can make your day with their humorous, if not off-colored jokes. However, since you’re going to have more interaction with these healthcare professionals than almost anyone else, you’d have to be in a coma to not know who the nurses are in charge of your care.
Resident: Depending on the degree of training they’re at, residents come in multiple forms. Interns are worn out, haggard, shells of human beings. Often they carry tremendous amounts of paperwork, small books, and 3-4 pagers/ cell phones/ shackles on them at all times. Like the medical student they hold almost no power, but are in charge of a lot of your care. Very similar to medical students, they also obtain your intake H&P, do most of the procedures and embarrassing jobs, and wake you from sleep. You can identify them, if for nothing else, by the fact that they have a long white coat and a name tag with an MD or DO following their name – often with a deer in the headlights look 24/7. Having survived the intern year, residents are more confident appearing, have less and less crap occupying their pockets, and see you less. If they see you in morning, you’ve already been awakened by a lower member of the team. They can also be identified by their position when a large mass of white coats enters your room – the more senior residents get to follow behind “your doctor” more closely. The intern is just before the medical student…the shame.
Attending: This can be “your doctor”, the one that you’ve seen regularly as an outpatient who admitted you to the hospital or is going to cut on you and take care of that problem. This may also be someone that you’ve never met before, but is in charge of your care – albeit from a distance. They bill you, are seen the least out of everyone involved in your care, and often are the oldest of the group. When the mass of white coats enter your room, they are first – always. If they begin to talk while others are talking, everyone else shuts up or laughs at their stupid jokes. We smile as they discuss their lovely weekend and “hop to it” when they ask for anything. Beyond that, look for the wet spots on their rears as the “team” kisses their ass multiple times during the day.
Tuesday, December 18, 2007
This feeling was uncomfortable and appaling. Over the last 2 years I’d been indoctrinated with the ideals of the “ethical physician” and the “professionalism” I must inculcate before meeting real patients. Despite the many fantastic thoughts and discussions we as a class had entertained, these forums, as well meaning as any, were utterly useless upon this first meeting.
Homeless, IV drug addicted, and crippled with disease, the patient came to us earlier that morning while I oriented to the inpatient wards. Upon entering the room I beheld a haggard, disheveled, and desperate form. Reeking of a filth known only to years of hardened drug use, I realized and withheld the primordial urge to retch and vacate the room.
“A full history and physical.” was the task charged me by my senior resident. "You will need to get a full H&P, write it out, and present it to me later today along with a differential and plan." Considering I'd never done a full blown physical, I knew I would need at least an hour with this patient and was not looking forward to our prolonged encounter.
Even though the intern was finishing up his H&P when I entered, I had to revisit every last detail already procured. The patient, clearly upset over this obvious intrusion, deferred several questions, cursed my stupidity readily, and resisted any attempts at a full physical. The anger inherent in the eyes was penetrating. Trust was not given nor expected, just more hurt, and he wished to inflict it before receiving.
Over the next week and a half “my patient” grew more tiresome. Pre-rounding was endless, useless, and ultimately absurd. The only information gathered was from forcing myself on the chest wall, abdomen, back, and head in order to elicit the heart sounds, breath sounds, and other physical tasks requisite of me after questioning the lethargic night nurses for overnight events.
Once able to hold a semblance of conversation, my patient soon withdrew from everyone and became mute. On one occasion I found my senior yelling in exasperation as she attempted to get consent for treatment. She no longer rounded unless the attending requested – leaving only the intern and I looking after the patient in the early mornings. The hate emanating from those eyes was palpable. We all felt it.
Regardless of the hate, the battles, and the apparent lack of concern about their declining condition the patient did not leave. Eventually a surgeon at another hospital agreed to fix the problem, and they were thankfully transferred off our service.
A month later, while on surgery, I heard a coarse, rough, and demanding voice yelling from a room.
“NURSE!” it boomed out of the darkened room. Despite the days of silence, I still instantly recognized it as my former patient’s.
My first instincts were to walk away and ignore the voice. I was no longer on this service and thus, not responsible for this patient anymore. However, for reasons still unknown to me, I walked into the room.
Upon my entrance I felt the same misgivings I had previously. There the patient was, improved in some ways, but in others very similar. I wondered if the reasons for another hospitalization were due to drug use and thought quickly about the cost of treatment they’d received that would surely never be collected.
I informed my former patient that I was not the nurse, but would let them know they were needed. Then, turning to leave, I said as calmly as I could:
“I hope that you’re doing everything you were asked to get better. A lot went into your care to get that surgery and I don’t think you realize how hard it was to get that taken care of…don’t blow it.”
I then walked out. A part of me felt vindication – speaking out against the wretch who hated those trying their best to improve a hopeless life. However, another piece of me knew that my innocence of doctor-patient politics had been forever lost. The urge to “want to help those in need” had been challenged and clearly weakened. By saying what I did I had only perpetuated its decay, amongst both parties. Despite knowing that I should have remained silent, I felt the need to let this person know were tried for them. We worked hard, against a system designed to hinder progress and I was upset by their seeming displeasure of my team's daily work.
This patient still haunts me. I’ve not seen them since, but I frequently think of them. I did not hate this person, but I entertained such desires at times. In my innocence, as a 3rd year medical student, fresh on the hospital wards, I wanted my patients to want to be helped. Furthermore I hoped that they would appreciate our efforts. Unfortunately I learned that it’s not that simple and patients, like those caring for them, are people first and foremost. Some are just better than others.
If you're anything like me then you have a favorite clothing item that you refuse to throw away. These shoes, over 2 years old, are the most comfortable footwear I've had in a long time. Wife hates them, asks me when I'm going to get rid of them, and blushes in shame if I wear them anywhere with her. They're well worn, dirty, and greyed, but are just not going anywhere. They've stood up to long hours retracting in the OR and have dealt with the ignominy of the OB "incident". I'll toss almost anything else, but I just can't seem let these go.
Monday, December 17, 2007
Actually I was one of those parents who, being a very loving parent, takes their kids to some crappy movie just to make them happy. Because it was crappy. Really crappy. There was such an abundance of crapitude in the movie that I began wondering who else wanted their soda to be spiked with hard liquor to ease the cerebral pain. A couple things that I just couldn’t get over, amongst the plethora of issues (would you say I have a plethora – sorry, just had to), were these items:
First: Dave got way to comfy with having talking Chipmunks in his house. Just like, eh whatever, lil’ dudes. Make me money! In fact, everyone was a little too comfy with talking rodents.
Second: I feel bad saying this, as I’m a big fan of Jason Lee’s, but he did not get the Alvin yell down – at all. It sounded completely phony and forced. Like he wasn’t actually yelling at anything (you know, like there wasn’t an actual talking chipmunk causing chaos in front of him). I guess some people are just better at pretending they're interacting with something that will be added later while others are stiff. Lee was stiff.
Another movie I saw over the weekend (yes, productive) was ‘I am Legend’. Good movie overall, lots of suspense, superb acting by Will Smith, and a post-apocalyptic/ zombie background – awesome. I do have one thing I’d like to say, though. Even though this was a movie I’d definitely want to see again, I wish movie makers would realize that not seeing every detail actually makes creatures scarier. At the end you’ve seen the zombies so much that you’re no longer jumping at them and actually laugh a couple times.
Oh yeah, I also got much needed maintenance done on my car. Like belts replaced, new tranie fluid, brakes, etc. So it wasn’t a completely wasted weekend. What did you do with your time?
Thursday, December 13, 2007
"How did Dairy Queen get pregnant?"
Oh god, I thought...here it comes.
"I have no idea." I stated, waiting for the obviously adolescent punch line.
"Because Burger King couldn't keep his whopper in his pants!"
Ah, yes, middle school.
Wednesday, December 12, 2007
“They’re gone. She doesn’t get any 'cause Santa’s mad at her. She not be good.”
I guess I’d better get to it and get at least one thing under the tree.
Monday, December 10, 2007
She, being on a Psych rotation, had been in the ORs occasionally when ECT treatments were being administered. We had talked, because we were curious of the process, and during that time our interactions were professional, brief, and pleasant. Running into her during a prolonged wait in an airport somewhere in the US, however, had a very different feel.
Now, I must inform you that she was quite comely. She also held the rare ability to take over a room upon her entrance and smells great. She is, essentially, a siren of healthcare. Patients loved talking to her, having her around, and she was always loved by the healthcare team. When I ran into her she still held this essence. What changed, though, was her demeanor.
She was nuts. Not just a little, either, but full blown crazy! She began by yelling "HI!" loudly, trying to hug me, which I deferred, then ran into a non-stop regurgitation of her interviews. She talked with great enthusiasm about the other candidates and what she thought about each and everyone, her voice reaching levels so high that I found others watching us. As I tried to get a word in edge-wise she launched into her time at the external hospital, how much fun she had, and the (here it comes) intimate interactions she had during that rotation.
I wanted to stop her, but she continued. Continued to let me know that she had met several nice people, they’d partied, and ultimately fucked. Hard - and long – and over and over again. She was detailed to the point of obscene at points, and I finally had to tell her my flight was close, said goodbye, and walked away. She again tried to hug me and I walked faster. A small crowd of lustful men and astonished women had formed a semi-circle around us, making my departure even more frustrating.
My mind was screaming – what the hell was that! Why did she feel that she needed to inform me of her “activities”? Why did she keep trying to hug me? Damn!
Thankfully I did not see her again, as I still had 3 more hours of waiting before my flight boarded, but I was looking around like mad. I didn’t want another encounter, with an X-rated description of her debauchery, and the expected attempts at physical interaction. Yikes!
Sunday, December 9, 2007
During this process of hating this area I had to consider doing a residency there. Certainly you jest. Come on now, if I hated it that much during the brief period I was there, imagine my misery 4 years later. No rank for you.
Wednesday, December 5, 2007
Mr. Bush has certainly qualified for this distinction in the past, but he's never deserved it more than he does now. Despite intelligence reports stating that the state of nuclear affairs in Iran is not as bad as previously believed, the "president" continues to make threats:
Bush said the new intel "contradicting earlier US assessments...would not prompt him to take off the table the possibility of pre-emptive military action against Iran."
Um, excuse me, Mr. President...just when are you going to learn from your mistakes? Is this not the same bullshit you tried to spin about Iraq? Do you really think you have enough trust with the American public and congress to actually try and start a 3rd front? No, sir, you do not.
You're acting like a child - refusing to hear the truth with your fingers in your ears chanting "nyah, nyah, nyah, I can't hear you". Why don't you sit down and take a time out? Please, for the love of God, just stop!
What’s been great is that we have a few of the traditional Christmas DVD’s that Daughter has, prior to this year, not been interested in watching. However this year she’s watched Rudolph the Red Nosed Reindeer, Santa Claus is Comin’ to Town, and The Grinch Who Stole Christmas (the real one and not that crappy remake with Jim Carrey) over and over again. She loves them.
Tuesday, December 4, 2007
1) I won’t read a blog if it has South Park characters or Looney Toons cartoons on the personal info area. Really. How can I take you seriously if I keep seeing some kid on South Park or Bugs Bunny to the left or right of your most recent post? I can’t, just can’t…so I don’t. Regardless of the content – I cannot get past that.
2) I have problems with my body image. Sounds like a girl issue, but in all honesty I’ve never been comfortable with how I look. I think it stems from where I grew up and the constant harassment I dealt with by my neighbors and classmates regarding my “weight issue”. Even when I was quite fit I thought I had to improve and have since realized that at times I had eating disorders. I’ve gotten a little better, but I’m constantly judging how I look, how fat I feel, and change clothes frequently based on what I think. I also find myself constantly looking at others and evaluating them just to compare. It's juvenile, stupid, and it gets old fast.
3) I’ve been a commissioned artist. While in high school and a couple times in undergrad while pursuing an art degree I had people request and purchase specific pieces from me. It was not a lot of money, but I loved doing it. One of the first that I did was when I was in middle school and my uncle wanted a watercolor of the Starship Enterprise fighting off a Klingon cruiser - he still has it in his theatre room near some memorabilia which is really nice of him. Now, thanks to medicine, I haven’t drawn or painted anything substantial beyond quick sketches in the last four years. Thanks a lot med school– well rounded personalities my ass!
4) To help with my image issues I’m also going bald. Wife has pointed out a little freckle on the top of my head that we’ve used as a reference point in pictures and while looking in the mirror when I buzz my hair*. The hairline keeps retreating, but only in certain spots, leaving me with an ‘M’ shaped hairline. Attractive.
* 4a - I cut my own hair
5) I have 4 tattoos – one unfinished and 2 that I’ve tried to have removed, but are still visible. I wear long sleeved shirts all the time in order to avoid having them seen, but at times in the OR I’ve had to expose them. For a while I was called "Dr. Tattoo" by some nurses. It got old quick.
6) I constantly evaluate people’s hands. I try to see how worn they are, do they fidget, do they keep them in their pockets, or are they sweaty? I inspect their nails and determine how clean they are, are they well maintained, does the person bite them, or are they dirty? Since doing some anesthesia rotations I've now begun to look at their veins as well in order to assess how large an IV I could use. I think hands tell a lot about a person without too much being said by anyone and are less likely to make someone nervous if you're looking at their hands for a minute or so.
7) I grew up a Mormon. Being from Utah that’s kinda the standard for a large percentage of the population and I was no different. I’m inactive now, but my name is still on their records and every now and then I get some call from someone who is supposed to check up on me. A lot of my family is still active and practicing in the church, but I’m under the belief that most religion is full of personal agendas and no one religion is correct. Therefore I’m agnostic – and loving it.
I won't tag anyone because I feel that you should just do these based on an interest. Go ahead or don't, I don't care (actually I do, but I don't want to seem needy).
Monday, December 3, 2007
However, despite the absurd complaints, the runny noses, the drunks, and the pride-swallowing displays I saw on a regular basis there was one encounter that made me realize that EM was truly not suited for me.
I arrived, late one day due to a morning conference, and found the usually cheerful chairman in a very foul mood. Thinking that his anger was due to our tardiness I tried to explain where we’d been. He quickly told me he didn’t care, told me to see patients, and walked into an exam room.
A few minutes later, while talking to an EMT student, I heard this doctor and a patient yelling at one another in a room. The chair left the room, clearly upset, followed by a strung out, gaunt, crazy-looking woman crying afoul.
“You’re heartless! I have cancer! I have cancer and you’re not doing anything for me! I always get this for my pain! You’re an asshole. I’m calling your supervisor and getting you fired!”
Chair, turning around quickly, pointing his finger at her: “No you don’t! You do not have cancer, there is not a shred of proof you have (certain type of) cancer, and I don’t care anymore. Go ahead and complain, I’m the highest you’ll get in this department and I’m done listening to you!”
With that he turned, finishing her discharge. When she tried to yell at him further he threw his hand up, like a teen-aged girl expressing her worldly wisdom with a quick “talk to the hand” and summarily dismissed this woman. She, furious, stormed away, paper in hand, cursing loudly and threatening to sue the “whole fucking bunch of you assholes!”
I was slack jawed - amazed at this seeming display of physician cynicism and the fact that he had actually thrown up his hand to shut her up. An hour later, as he predicted after she left, an administrator came down to the ED with the patient and confronted him.
Admin: “Why didn’t you take this patient seriously? How can you be so certain that she doesn’t have cancer? I want you to take care of her and do as she requests.”
This was all said to the chairman of the ED, with the patient acting like a spoiled child, arms folded over he chest and displaying a most distasteful “I told you so look”, while the staff stood around, trying to look busy, but clearly watching to see what would transpire.
The chair didn’t budge. He called out the administrator, asked what degree he had that conferred upon him the power to diagnose this woman with cancer when several physicians agreed that there was no evidence, and told him to write the script himself because he would not – he was not a drug dealer. He then added that, if this was the type of support they could expect from the administration and CEO they’d been promised during their monthly meeting, this would be his last shift.
Of course the administrator, trying to remain calm but clearly unnerved, relented and informed the woman that, unfortunately, they would not be able to help her at this time. They walked away and a nurse said he was inviting her to fill out a survey in order to help “increase efficiency”.
Aside from the humorous and tragic aspect of this case, this settled any desire to enter emerg for me. There was no way that I would tolerate that kind of abuse, by people who held MBAs or MPHs and knew nothing of actual medicine and only cared about customer service and maintaining a "hotel" image. There was no way I could stand up to that form of degradation regularly and feel that my sacrifices had been worth it. Medicine is not in the business of letting people "have it their way" only to get sued for complications. While it's not for me, I applaud anyone who can look at that on a daily basis and come back for more.