More Truth Than Not

I read this article when a couple blogs posted about its topic. Some were naysayers, stating that it painted a bleaker future than really necessary, others were more open to the advice. I noticed that many of the younger bloggers identified with the article than the "dinos" who, of course, viewed this with a grumpy hurrumph! and went back to their job of trying to keep their investment portfolios from completely going under.

Of course I kid, but there is a lot in this article that I've identified over the last few years, which several physicians warned me about, but I didn't listen. If anything - to those out there not in medical school or medicine, it's really important to review information like this before deciding to go into medical school. Take a look at some of the comments as well, that will give you a good idea what people think of doctors.

Oh, and happy mother's day.

Tragic Realization

Picking through a Civil War book of which I'm quite fond I came across an atrocious image: masses of ravaged arms and legs, piled waist deep, gathering flies and rotting as a surgeon and his staff, covered in stinking, blood soaked leather and cotton aprons, began again on another poor soul.

The anesthetic being delivered came woefully from a single chloroform soaked rag and a prior heavy drink of whiskey. In the picture one of the men held the soldier’s head with that rag, covering his nose and mouth. This was the extent of anesthesia – and that being rarer as the war raged – that many a man received after having their limbs decimated by Minie balls, canon shrapnel, and grape-shot.

Surviving this extreme assault on an already destraught, damaged mind and body, the soldier faced the inevitable infection that would arise and hope, praying pitifully, that God would spare their lives. Many prayers were not answered and thousands died from postop complications.

We’ve made leaps and bounds in 140 years, people. As much as people don't understand anesthesia, I'm sure they're grateful that they don't have to undergo such horrors.

What Savior?

Where will all of the primary doctors come from? Serious question – not rhetorical. Despite the assuagements from various people that the PCP is and will be filled by foreign medical graduates who’ll be more than happy to work in rural environments, I’m concerned.

For instance, many of the senior foreign residents in the Medicine program at my hospital are talking about taking hospitalist jobs when they finish. I’ve yet to hear one who has discussed going into private practice.

Not one.

And why is that? Because docs are greedy, money-grubbing, unethical whores, worshipping the almighty dollar in a gluttonous orgy of padding profits and ordering unncessary exams while Rome burns (or something)? Or is it because the government, that same government that plans on swooping in and “saving” American healthcare, is actually the etiology behind all of this?

Think about it. Medicare is the main stimulus for insurance reimbursements for everything from major to minor insurance companies. “Do as I’m doing, follow, follow, me” should be the mantra of Medicare as they cut payments and dare docs to retaliate. Private insurance companies take heed, and follow similar cut backs in payment - rather than acknowledging that their reimbursement schedules are messed up.

So congress, rather than being smart about cost-effectiveness, believes that in order to balance their budgets (oxymoronic term if ever there was) they have to pay hard working doctors – who've spent more than a decade getting an education – less and less. We're now seeing the deliterious effects that years of this foolhardy maneuvering has caused; removing office-based, primary care out of resident’s minds.

Further insult comes from beauracratic nonsense that, while not completely government controlled, is basically just a few votes shy of becoming part of the FDA or some other monolithic entity. Of course I’m speaking of the idiocy known as JCAHO and all of the ridiculous limits and strangleholds they place on patient care disguised as “safety measures” which only leaves the physician spending hours digging through minutia and dead-ends in order to "meet standards".

Bullshit.

Yet, millions of Americans are being dupped into believing that they must have universal coverage in order to get healthcare – and they’re buying it hook, line, and sinker. It has taken center stage over most every other consideration during the recent campaign speeches. The economy? Iraq? Ha, mere annoyances compared to this impending "disaster".

It infuriates me to see people who are highly qualified physicians avoiding the work that their residency was initially designed towards. I don’t bemoan them. Hell, I’d being doing the same thing. What I find sickening is the idea that the government will fix this. That the good ol’ US of A can be saved by lawyers and career politicians who know as much about medicine as they’re able to maintain party neutrality and an open mind. Ha.

Not A Real "Doctor"

Dr. Jarvik is not a real doctor - at least in how the Lipitor ads were trying to make him appear.

Although he has a medical degree, Dr. Jarvik is not a cardiologist and is not licensed to practice medicine.

Learning about his history earlier when he began hawking the drug instilled in me the desire to never prescribe it. But at least now Pfizer has pulled the ads and I won't have to look at him talking to "real doctors" in the hospital or running with his goofy looking kid.

Ah, Dr. Jarvik. How you will not be missed.

Just Go and Read

You have to read this commentary from the Happy Hospitalist. Dead on.

America has lost her way. We once were a nation of proud people. We were once a nation that took care of itself. Now we're a bunch of freeloaders blaming "the rich" for everything that's wrong.

You want universal healthcare? Then you pay the damn taxes to fund it. I sure as hell won't.

Getting Better Care

Concierge medicine or retainer medicine has been discussed by other, far more eloquent bloggers. I suggest that you read their material before continuing with this thread – but that’s just my humble opinion (don’t expect this to tell you much of anything about the topic as I really haven’t researched it to the Nth degree - more just my opinion than anything).

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.

Avarice and Health

Many bloggers are discussing the nature of people going into extreme debt at this time of year – procuring expensive electronic items with little to no argument about the cost. It is, of course, only natural to make the connection between the money spent on frivolous expenditures while we wring our hands over what to do about the poor and healthcare. What must be seen, if you haven’t already seen the absurd juxtaposition is this: these same people, who spend several hundreds to thousands of dollars for one day’s avarice are the exact same who bemoan the cost of healthcare and villify the physician.

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.

You Don't Have Cancer

During my 3rd year surgery rotation I was allowed to work in our “ED” for 2 weeks. While it was called an Emergency Room it was really nothing more than an urgent care clinic for the homeless and stupid, but it’s what we had. I had some thoughts of entering this field, but had been wavering since beginning my clinical rotations. The cases regularly seen by our department and the nature of the work soon wore on me and forever soured me against this specialty.

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.

Automatic Automatons Part Deux

“Sweeping generalizations should not be made about any [field of medicine]”.

I couldn’t agree more with that statement. The premise to the last post was not to slam nurse practitioners and physician assistants, but rather identify the flaw inherent in the retail clinic model of healthcare reform.

Often these clinics are staffed by younger, less seasoned professionals who are not well supervised and often work within the shadow of the behemoth that employees them. They feel the pressure to move patients, treat them similarly based on error prone algorithms, and give drugs for anything that looks infectious. That is not simple hyperbole, but a fact. I’ve been informed by several people who’ve either worked in or for these types of clinics of these types of pressures and have experienced a similar form of medicine early in my third year of medicine in an office that employed two PAs and 1 NP so that the doctor could manage his “businesses”. The pressures levied on those three providers to get as many people in and out as possible was tremendous. I could understand, as faulty as it was, to give amoxil for a 12 hour case of sore throat.

What scares me is the fact that you are being treated by people with less education than I’m at currently and have to deal with administrative bullying. When I enter the medical field as an intern I will have some autonomy, but leveled with so much restriction and guidance it will make me feel powerless - like a med student again. By it's nature, a residency allows young doctors the chance to improve slowly, while their training and skills are evaluated and redirected as needed by more experienced faculty. They are taught to be brutally critical of their and other's performance as it related to outcomes and current clinical practices.

I don’t feel that someone with three years of post graduate education who receives little to no feedback on their patient performance beyond “move more meat!” can be expected to improve. In fact I feel that these clinics will only dampen the skills these providers have developed in order to get patients in and out more quickly.

Certainly there are physicians out there that are less than admirable about their patient encounters and prescribing practices (since I’ve worked with a few I should know), but I truly and honestly believe that once they completed their education they were far more capable of handling patient’s complaints and evaluating them properly using evidence based medicine than a 3rd year medical student. Because that’s honestly what you’re getting with a retail-clinic provider fresh out of school.

Automatic Automatons

There are some things in medicine that irk me beyond rational thought. These quick, “urgent care” clinics are definitely a topic that incites rage and hatred in me. They are, to a word, pathetic. Pathetic excuses for healthcare, pathetically trained or motivated people caring for patients, and pathetic attempts to “fix” the healthcare system in the US.

Part of the reason they are such a poor medical facility is due to the people treating most of the patients. NPs and PAs, free from a great deal of medical supervision, are often found handing out erroneous and falsified diagnoses - only to then treat everything with antibiotics or other unnecessary medications. An example of this irresponsible behavior is a story I heard recently encompassing most of these qualities:

A mother whose adult son had a sore throat and was too busy to get it evaluated, went to an urgent care clinic knowing that she could fake his symptoms and receive a Z-pack. This was done because her doctor wouldn’t normally give medicines unless specific tests were positive. She, of course, received the antibiotics (despite having ANY illness) and proceeded to give it to her adult son.

This kind of malpractice (for it really is irresponsible medicine) only increases the drug resistant bacteria that we’re seeing and encourages patients to demand drugs they don’t need. What’s worse is the notion that medicine is like a cookbook and all symptoms should be treated the exact same, regardless of testing and patient profiles.

For all the complaining patients do about their long waits, the doctor’s refusal to give them some drug they read or heard about, or their increasing dubious belief that they are as able to diagnose themselves as effectively as their PCP these clinics are not the answer.

Consider the story above: what if the antibiotics given reacted badly with another medication, or had to be altered due to liver or renal failure, or caused a severe allergic reaction? All things that a PCP would most likely catch through charting or questioning but would characteristically be missed by a NP or PA trying to get as many people in and out of their fast-food-medicine chain as possible.

“What the hell do I care about giving medicines without proper test results? It’s a pain in the ass to do it any other way and it takes up valuable time. That's not what Walmart/ Walgreen's/ Target is paying me for”.

Instead of responsible and smart medicine, what you have are people who will not use medical evidence to properly treat patients and essentially run a medical McDonald’s – have it your way. Sore throat? STREP! Neck hurts? LORTAB! Sniffles? SINUSITIS! To add to this obvious disparity is the fact that these clinics are often owned by corporations who want people to be sick and have to go to their pharmacies. It's not rocket science to see how there's a conflict of interest.

Now I don’t think NPs, PAs, and CRNAs are entirely bad - quite the opposite. They are important in that their job role allows overworked physicians time to focus on the more complicated patients and running their practice while more minor ailments and procedures are analyzed and treated - after a quick review with the physician. However what I do find absurd is the idea that they can take care of patients without strict physician guidance as often occurs in these retail medical centers. Regardless of their time, they haven’t received the training requisite in order to differentiate between disease processes that appear very similar, nor is it expected.

If you still haven't jumped on the bandwagon, realize this: a nurse is trained in a very different way than a physician. They are not expected to figure out the pathophysiologic basis of a disease, the subtle interactions between comorbidities, the ever increasing need to be smarter about treating seemingly simple infections, and the evidence that alters treatment regimens amongst patients. Their training is based on recognizing a defect or a problem, alerting the appropriate people, and following a procedure or "order". If a patient has X, then give Y. If this happens, call the house officer or the patient’s doctor for direction. Adding a couple of years to the training does not inculcate the need to think beyond this automatic process, no matter how much you “shadow” a physician.

Experience certainly lends itself to making people think they know more than they really do. Twenty years in the ICU will definitely make you appear smarter than the intern or second year resident rotating through that service, but only for a brief period of time. Of course you’re going to know more about vent settings, how to respond to codes, etc. than a newly minted MD; but a seasoned physician, who has spent some of their time in the critical care arena will run circles around you - no matter how long you've worked there.

The physician trains in a wide array of specialties for which they are expected to understand a great deal of complexities, is responsible for the outcomes of their patients, and understands more about the overall process leading up to and currently occurring in that patient than an NP, PA, or tenured nurse could hope. A few decades of experience does not overcome the difference in education. A physician with twenty years including residency will always come out on top.

Residency is designed towards this goal. It is the resident’s training, adding on top of the knowledge procured through four intense years of medical school, that makes a physician more than just a “medical mechanic”. Performing a task a million times is not the same as medical knowledge. It is habit, and, as often seen when new policies are passed, is often hard to break.

Urgent care clinics are not the answer to the healthcare crisis. If we expect to take care of patients in better ways, to reduce drug resistant bacteria like the current MRSA “epidemic”, and have more advantagous outcomes we must realize that physicians are not replaceable by technicians. The years of training that doctors receive and the strict environment that they receive their education in makes a physician far more capable of truly evaluating patients. What you are receiving when you see a physician is a decade or more of increasingly detailed knowledge and arduous training that enables them to treat people effectively. Four to six years of training is not even close.

ER Abuse

Scalpel has been talking about the pain scale and pain-seekers recently. Reading these entries got me thinking about a trip I had to an ER during med school and the lasting impression it left with me.

Between 1st and 2nd year I had a research project that fell through. Since this occurred late in the year I decided to just get a job and work over the summer. I don’t really like research anyways and my Orthopeadic frenzy had significantly subsided so I didn’t feel research was absolutely mandatory at that time.

I returned to work for the company I’d been with prior to med school and was given a job in the backroom where I would stock and pull items for the salesfloor. This entailed some heavy lifting which aggravated my back already damaged from poor weight lifting during high school. I began taking Aleve in the mornings before arriving to work in order to move better and decrease the stiffness I was appreciating in the morning. This seemed to be working well until 4 weeks into the job.

One Saturday morning I awoke with a great deal of pain. I found that I had a significant amount of trouble getting out of bed and walked bent over since straightening caused a great deal of discomfort. Some NSAIDs and attempts to stretch out my back resulted in little improvement. Deciding to rest my back, I laid down for a period of time, hoping for a “miraculous” improvement. Instead my decreased range of motion and pain only increased.

I found that I couldn’t stand up at all. In fact, trying to walk resulted in me crying out briefly a rather nasty curse and falling to the floor. Wife found me crawling on the floor, unable to get out of this position, heading to the living room to sit. She decided that there was something very wrong and that I needed to go the ER. I resisted, thinking it weak and pointless; after all this wasn’t an emergency – right?

She persisted and I finally caved. The ride to the ER was torture, with every bump knifing through my back. In order to decrease the pain I was in the fetal position the whole ride. On arrival I tried to get out of the car, only to fall on the sidewalk from the pain. Wife ran in and found a volunteer who brought out a wheelchair. Humiliated, I again resisted, but eventually had to sit and be wheeled into the ER. They wouldn't let me crawl.

The staff was courteous and quick (not very busy at that time of day), but I continue to feel that they thought me a druggie. I rated the pain a 5/10 since I didn’t want the stigma of being a “seeker” and tried to be as helpful as possible in relating my history, but when everyone who wants drugs mimics this kind of pain I just knew they were talking about the “drug seeker” with lower back pain in room 12. It was frustrating to know that I was in very serious pain, had fought seeking treatment, and just wanted to be able to walk without severe shooting pain, but that because of parasites in society I was most likely considered an addict.

After some x-rays, a perfunctory exam by an NP (I wasn’t even taken seriously enough for an MD to waste his time on), and a shot of narcotic in the ol’ butt, I was discharged to follow up with my doc.

The narcotic and muscle relaxants worked wonders, allowing me some increased motion, but I was unable to return to work. An MRI done later per my PCP showed osteoarthritis of the lumbar spine with small herniations. I was informed that the kind of work I was performing was out of the question with my back and physical therapy was eventually needed for me to regain my normal mobility.

Now, I tell this story not as a lesson to be learned for all ER docs. Rather it is the reason that I find so many of the patients I’ve seen - who claim 10/10 pain, want Lortab or Dilaudid since they have “allergies”, and abuse our system - completely abhorrent.

It is the reason I decided to opt out of Emergency Medicine. I was just too jaded. It is because of patients like these that those who truly need the services of the ER are often initially considered addicts. It's because of asshole patients, cyring wolf constantly, who abuse our system that ER's are practicing defensive medicine. It's the reason I think ER's should get a free pass for all frequent flyers who they don't believe who present with an actual problem. You weren't believed? Too fucking bad!

Mining for Gold

“How’s your pain today, Ms. Drugseeker?”

“It still hurts like hell!”

“How’d you rate it?”

“Same as yesterday, a fucking 10! God, why don’t you give me anything?” Her eyes demonstrate a clear desire for pain meds; desperate and conniving as is often seen in connoisseurs of opiates.

“We are giving you pain medications. We aren’t going to increase the dose at this point as you've yet to gain any relief over several days.” I lie to the patient. Really we know she’s full of it and we’re planning on taking her down, giving something for her iatrogenic constipation, and giving her the boot.

I proceed to complete the requisite physical check which includes the patient jumping with “pain” each and every time I touch around her left chest. Oddly enough every test performed to this date has come back negative. Wonder of wonders. She doesn’t have ACS, an MI, or any other problems - except drug addiction and vagrancy. I’ll be glad when she’s outta my hair.

I learned quite early in my 3rd year of training that some patients need a place to stay, some need a bed and a meal for the night, and others just want drugs and use the hospital for these purposes. Things that I knew already, but never quite understood how it was that they were able to manipulate the system so well. I've seen the scams and read about others. Oddly many are very similar, but unique with the person involved.

Ms. Drugseeker will receive a bed because she is middle aged, has abused her physical and psychological health for years, ingests varied amounts of drugs which she obtains by doing unmentionable acts, and has not seen a regular physician since Nixon was in office. An abnormal EKG results and labs will most likely surface, relegating the on-call team to take on this freeloader in a useless search for the etiology.

The patient stays, getting a bed, free food, free healthcare, free drugs, and a place for her hubby to sleep as well while the doctors, nurses, and medical students try to not think about the waste of money this person has become. Hubby remains sedated throughout the process until he hears they're being "evicted". Then he suddenly is concerned about his wife's condition.

Unfortunately for our society this is an all too common occurrence. Many private hospitals won’t take them and will either give a quick drug cocktail and/ or street the druggie. Then the charade plays out all over again, at another ER, another clinic, wasting the same taxpayer dollars; but nothing can be done because god forbid if the constant abuse of heath resources by a parasite might actually lead to the discovery of some illness. Then the lottery is in town.

Hell, we might find gold in them thar hills…so wouldn’t it be a shame to not go looking at the same or slightly varied complaint for the upteenth time while knowing full well that you‘re most likely not going to find anything other than someone who can only tolerate a “D“ drug? That’s what a litigious society has constructed for our kids.

Personally this abuse pisses me off. If we’re going to ever have a healthcare system that has any potential to become universal this exploitation has got to stop. Personally I like the idea that people have a certain amount of points that they can use. Use it up and your done for the month, year, etc. If you’ve been diagnosed with a legitimate disease that will increase your healthcare use then you receive additional points.

This would reduce the overuse of ER’s for minor ailments, reduce the ICU stays with ridiculous attempts to prolong lives already long lost, and might just curtail drug seeking abuse. Of course there's a lot to be desired from this plan; it won't define what an actual "emergency" is, it won't create jobs and decrease poverty/ addiction in many abusers, and it won't take care of the illegal immigrant crisis. But I like it in it's infancy.

Till then the exploitations will continue, the drug seekers shall refine and perfect their lies, the viral URI's will get treated with antibiotics at 3am, illegal immigrants shall continue to invade ED’s for each and every complaint to avoid INS troubles, and my taxes and health insurance premiums will continue to increase.

Oh. My. God

I just read this over at Musings of a Dinosaur. I can’t be more ticked and nauseous over the outcome. I will try and write something more about this loss of freedom of speech and expression that we, as a medical community, are quickly losing, but for now I just can't. It's overwhelming currently.

It’s enough to scare anyone and make them consider what we write and just how anonymous any of us truly are.

Dear Dr. Flea… I wish you peace and tranquility my friend. Peace and tranquility.

God.

Parasites

The way some people carry-on you think they were royalty. In a hospital that caters towards the indigent and uninsured I see a great deal of unwillingness in patients to help themselves out of their dire situation who will, at the drop of a hat, threaten to leave for a better hospital. They don’t like what’s happening here and they want better care. In short they feel entitled.

But here’s the thing: these other hospitals that these tragic patients want to have their care transferred to won’t see them. They’ll kick their asses straight out the door should they try and walk-in and they sure as shit won’t receive them as a transfer. Why? No ability to pay for services rendered.

So instead this hospital accepts these patients, hemorrhaging money by the millions each year in order to give the extremely poor a place to receive equal and fair treatment. Because of the huge financial pitfalls there are areas where we suffer. We don’t have the newest, most expensive, and most advertised machinery or treatment options. Instead patients receive quality care with methods proven to work. And all at almost no expense to themselves (since we all know they’re not paying for anything anyway).

Despite these efforts and the obvious level of gratitude that should be inherent in these people I often see them ungrateful. Upset at the conditions they “perceive” in a place that’s never out of the red.

“I’m going somewhere else. They’ll take better care of me.”

“You don’t know what you’re doing. Over at (huge research hospital with lots of fancy and expensive new equipment) I’d get this test done. I’m outta here.”

“I’m leaving AMA. I don’t care what you say. Some doctor out there will take me and care for me without insurance and a stable income.”

I hear these lines or variations everyday. Trying to explain to a patient who has not had a job in over 5 years, drinks 12 or more beers a day, smokes like a chimney, and has absolutely no means of paying for services for his congestive heart failure, kidney failure, and rectal cancer that no doctor in town will touch him other than those currently seeing him is just futile. They don’t get it. They don’t want to get it. All they want is a handout and feel entitled to the services and care received by the best insured and wealthiest in society.

I guess it’s the delusional aspect of many of these patients that got them where they are in the first place. Believing that someone will always take care of them, trusting in the fact that Uncle Sam will never stop giving them money or food or clothing. Ensuring that they’re not responsible for their own damn care – ever and behaving like spoiled children with surrogate parents. Why else wouldn’t they think they can get that new drug, fancy treatment, or costly surgery with little to no cost to themselves? It’s how they’ve been living their entire life.