Mission Creep

The conventional wisdom is that the American health care system is broken. This is the party line parroted by the various media organs of the dependocracy in their attempt to stampede an excitable public towards socialized medicine. Like a lot of the conventional wisdom, the idea of a broken health care system gets repeated so often that it has become a cliche, something that people spout in a self-righteous reflex. It is certainly a pleasant metaphor and an easy one for the people to get a handle on without having to think about the real complexities of delivering zero-defect medical care to a largely non-compliant public, most of whom care more about their cable television and their personal watercraft than they do about their health.

In other words, while you can poll the public and health care makes it to the top of the list of concerns, most people, at least the ones sucking up a disproportionate number of somebody else’s health care dollars, spend considerably more on cigarettes than they would ever dream of spending on medical care which shows you its true importance to most people.

Putting aside the fact that there is no health care system, just a collection of independent hospitals, clinics, and private practice physicians, the system is not so much broken as it is a tool being used for a job for which it was not intended and for which it is ill-suited, namely being completely responsible for all aspects of the health of a feckless and helpless public for whom the thought that they are responsible for their own health is completely inconceivable. We pay lip service to the idea of patient-centered health care of course, and including the patient as an equal partner in medical decisions is the New Religion. In our society however, where a physician can get sued for not having written on the discharge instructions for a dead crack dealer, “Return to Emergency Department if chest pain returns,” well, there just isn’t as much equal partnering as you’d like to believe.

In fact, there’s none to speak of where it counts. Not an artery hardens or liver fails without a physician somewhere, somehow being blamed. Personal responsibilty having long ago been abandoned in every other part of society has finally been driven from medicine which is the one place above all others where it is critical. The medical schools, for their part, have moved completely away from the notion of expecting patients to care. To even breathe the words “personal responsibility” is to invite criticism from your instructors who despite their professed love for their patients view them as contemptible creatures who are incapable of making rational decisions and little more than slaves to their conditioning. As a result there is a natural tendency to try to become deeply involved in the lives of the patients in the hopes that some combination of cajoling and psychobabble will save them from themselves.

This creeping paternalism is the new medical paradigm and, as it will serve to dissipate finite medical resources instead of concentrating them where they may do the most good, it could not have arrived at a worse time. The level of involvement required to change bad habits is simply more than we will be able to fund. Every patient cannot have a dietician, a therapist, a substance abuse counselor, and a life coach. It’s too expensive. They’ll be lucky to get a physician and he’s not going to have the time to arrange their personal lives, especially when everybody is entitled to all the free health care they can suck down.

Almost every social pathology you can think of has it’s origin in a lack of personal responsibility. As much as we continue to move away from encouraging it we will be continuously chasing the tiger and wondering why he keeps getting bigger and meaner. The solution is a simple one but hard for those deeply invested in paternalism to stomach.

Is it Worth It Redux

Look, if you like medicine and your specialty it is “worth it” (whatever that means to you). I say this after receiving a lot of angry emails from people chastising me for having the unmitigated gall to imply that income potential is a legitimate factor in the decision to pursue medicine. Who am I, yer’ friggin’ mother? Make your own decisions. If medicine is that fantastic a career than I am just a lone crackpot and the desire to smack me down is therefore inexplicable.

What can I say? I assure you that if the potential salary was not substantially more than what I made as an engineer I would never have made the switch. I like Emergency Medicine just fine and am glad to be in it but if all that was waiting for me salary-wise at the end of the dark tunnel of medical training (the light at the end of which I can now see) was the same income or less than I made before I decided to throw it all away, well, I’d be pretty disappointed. And my lovely and long-suffering wife would be devastated. Marriage is a partnership and, while my wife is happy that I am in a rewarding and useful career, the usefulness and intangible rewards of it don’t put vittles on the table and logs on the fire. There’s got to be some bacon to bring home for her to fry up in a pan or it’s just a selfish personal hobby of mine for which she gave up security, stability, family, and financial solvency.

In fact, my wife cried when I didn’t match into Emergency Medicine the first time around and scrambled into Family Practice instead. She knew instinctively that on the balance sheet, the whole adventure had now become a rather bad investment and one in which we might never recover financially. For what Family Medicine physicians make I may as well have stayed in engineering where devoting the time I did to medical training would have paid better sooner. And without the call, the abuse, the humiliation, and the constant feeling that my gonads are not my own.

Why this is hard to understand is beyond me. And if you think I’m unique in my point-of-view then stand by to be surprised and disappointed in your colleagues.

39 thoughts on “Post-o-rama

  1. Brilliantly written, as usual. Have you thought about putting some of this material together in a book format?

  2. Is your wife some kind of gold digger?

    Just kidding actually. I mentioned to my husband that I fully expected not to make that much money given the way that the health care “system” and political climate is headed, and thank god he had a job that pays well. You should have seen the dirty look he gave me! At least when I’m done I won’t have any/much debt, which is more than I can say for some of my classmates.

    I thought about whether, if the debt issue were erased and doctors could come out of school not owing anything, would they be content to earn less? And I came to the conclusion that, maybe some of them would be willing to, but given the hours the typical doctor works, they likely wouldn’t be content earing much less. Consider what most other skilled professionals who work 60-80 hours a week make.

  3. I agree with your point about income potential. Obviously it doesn’t make sense to go into medicine if you’re in it only for the money, but it’s clearly an important consideration. I really like medicine, but like you, I *never* would have made the jump from my previous career into medicine if I didn’t think there would be a substantial jump in income at the end of the road. And in spite of all the naysayers and doomsday scenarios you can find out there (especially on SDN), I don’t expect dramatic drops in specialty income anytime soon.

  4. People who think physicians shouldn’t be VERY well paid for the service they provide should be rounded up and flagellated for their absolutely galling stupidity and lack of vision. The money they spend on everything else while somehow thinking medical care should be free is in an absolute scandal.

    On the other hand, it is kind of sobering that incompetent physicians can keep up an excellent income flow until they, say, amputate the wrong leg at surgery, show up drunk to surgery, etc etc I am amazed at the
    tolerance for these people.

    Ditto for physicians who make a great impression of themselves, read on.

    Patient has a cervical lymph node biopsy, wakes up…shoulder is KILLING me…. continues killing her through multiple rechecks, referral to ortho where she receives bursitis injection, courses of PT, finally months later she develops atrophy and the neurology people know what’s going on before she gets to their clinic.

    She had gone back to the surgeon two weeks postop, who spent 2 minutes with her and said “it’s nothing I could have done”.

    Except cut her spinal accessory nerve where it gets kinda superficial….

    Her graft took, patient still has pain several years later, doesn’t sue, bless her heart, doesn’t believe in it.

    “Nothing I could have done”, indeed.

    But I digress. A single payor sure would make things less complicated. In France, everyone pays into the health system, a substantial monthly premium, like 400$ a month.

    The doctors don’t get paid as much, but have a relatively hassle-free life and tons of respect. They also graduate medical school at 24 and don’t have any concept of med school debt.

    Would a single payor necessarily mean a huge drop in physician income in the US? That is the question to decide, because from what I can tell, the ridiculous number of employees a physician needs to have in the US just to deal with the billing quagmire strikes me as a huge inefficiency. Everyone says the government is less efficient, but we now have the internet. Hell, I printed my DEA certificate off of my home computer the other day.

    How do we really know the government couldn’t act as an efficient payment broker that would accept currently established private fees for services?

    (And yes, I am really ignorant on the subject, so feel free to flagellate)

  5. Panda, my brother. I love reading your blog. I’m also a non-trad med student, about to enter my 2nd year. I appreciate the realities that you are brave enough to write about. Keep it up!

  6. Pre-meds have been indoctrinated about the money thing. I don’t know how it happened, but some of us learn not to refer to the obvious truth that it’s nice to be paid for hard work and some of us internalize it to a ridiculous extent. They grow up to propagate the system on others.

    I don’t understand why you’re so defensive. You’re in a better position to understand the truth of what you’re saying than your readers. I do think you’re somewhat overly negative. I hated my last job at times when I left it. I expect to hate this one at times.

    I question your characterization of the “cool years” of med school, because I hope that’s very individual. It’s good to run my own schedule, but it’s not that “cool” when I schedule myself for 12 hours of study a day, in-class or out. It would probably be easier if I was a slacker, but it’s not all that cushy from the viewpoint of trying to do my best all the time. At least it’s a choice, which is your point that I agree with, but then for a civilian student all of medical training is a choice. You might not like the consequences, but you could always walk out.

  7. The money is important and anyone that has GONE through this training and life have to admit that. But it is not everything and as Panda mentioned, you figure out what makes “worth it” in your damn head! I am happy to this issue being discussed and am happy to discuss my “older med student” take as well. I thought a lot about the money (I have 10 less earning years than my compatriots) and the fact that starting medicine at my age (I am not married) meant probably giving up a traditional family. I am still here. We all have our list of pros and cons and that is was separates the types of people that will choose medicine in the future. Panda is just voicing some of his and that is cool.

  8. People who think you’re too harsh about medicine and about your advice to people considering the career should be promptly directed to Hoover and

    That man makes you look like medicine’s cheerleader on crack.

  9. Incredible writing, Panda. Personal responsibility for healthcare is the elephant in the room. Most of the data that policy wonks throw around would probably be better used if it was quilted and placed on a compact roll next to the john. When you consider 2/3 of Americans are obese, how could any data not be look favorable for other countries compared to ours. Physicians actually making lifestyle changes in our population is akin to Don Quixote fighting Windmills.

  10. No. No it’s not. Would you take a pay cut to make a difference in one person’s life? How much of a pay cut would you take? Would you look back after twenty years of that pay cut and say, “You know, that guy in whose life I made a difference is a real asshole and I’d rather have had all that money I lost.”

  11. HEY!

    Can someone tell me why a single payor who pays at currently established market rates is an impossible dream? Without resorting to talk of personal responsibility????

    Listen, smokers save the system money, if you don’t believe it, look at the respected study on the subject a few years back in NEJM. They die and don’t suck up all the medicare dollars, god bless them. Just remember, Winston Churchill was a smoker and Hitler wasn’t…most of the valuable work that gets done is done by smokers (RTs, for example….)and I will stand by them every time.

    Fat is the culprit, and some genius is going to find a safe drug that will
    make people really dislike overeating, soon.
    Maybe rimonabant is it.

    And rank waste: G-tubes for Alzheimer patients and all related absolutely DISGUSTING practice that goes on. I am undecided which politician I would be most likely to kill if I were ever unfortunate enough to meet him- Bill Frist (“Terry Schiavo is lookin’ purty good to me, think I’ll take her out to the ballgame”, Bill Frist) or Ralph Nader.

    Let the information flow, without any condemnation of smokers, please.
    Unless they are also obese, have really, really bad gum disease, psychiatric illness, smell, and say within one minute of the encounter (“I don’t like Doctors, nothing personal…”..or..”I don’t go to Doctors”).

  12. “Can someone tell me why a single payor who pays at currently established market rates is an impossible dream? ”

    Simple, because the single payer does NOT pay at the market rate. They are the only paying customer. There is NO market. They will set the rate at whatever they want, and we’ll all be eating tuna out of the can because we can’t afford bread.

  13. “The doctors don’t get paid as much, but have a relatively hassle-free life and tons of respect. They also graduate medical school at 24 and don’t have any concept of med school debt.”

    – I’ve worked with physicians from all over the EU, and nobody gets respect like US physicians. People come from all around the world to train here because publishing in a US journal can make their career. Back home, they are treated little better than pipe-fitters. But don’t take my word for it – Google MMC and MTAS and you can see how well the British government has treated their medics.

    “Would a single payor necessarily mean a huge drop in physician income in the US?”

    In Germany docs get paid ~50k a year, which would mean that pedicatricians, the lowest paid type of physician in the US, would get their paycheck cut in half.

  14. Why not get rid of ANY corporate/government paying system and let the market determine rates?

  15. There’s not enough of bread and circuses in that idea, Surfie. Everyone likes bread and everyone likes circuses, so more bread and circuses, please!

  16. Thanks for the post PB. Makes me feel a whole lot better about NOT going to medical school in this country. In spite of the (undeserved) denigration and discrimination of FMGs, at least it didn’t cost me, how much did you say it was? 500K to be in a career that I find largely fulfilling in spite of all the current problems of the system.
    In response to Rxnman’s comment, while true that many of the EU docs in France and Germany for example, make far less than docs in the US, they also have a single payor system which cuts down on their admin costs, and the gov’t pays for their healthcare, child care, and the education of their children (and I’m talking about good education), so I’d say it’s about even.

  17. docwhisperer, I could have gone to my state school for a total of $80,000. I opted for a school that’s another $40K, but it’s nowhere near $500K.

  18. You know, Docwhisperer, my healthcare and child care costs are minimal (healthy family, stay-at-home wife). We pay about $4000 a year in property tax, most of which goes to our school system which is actually pretty good.

    I’d rather make $240,000 a year as an EM attending even with my $250,000 medical school debt than make $60,000 per year and get all the cradle to grave benefits. There is no such thing as a free lunch. Somebody pays for those benefits in Europe. I’ll wager that those surgeons in Germany, even though they are making paltry wages still are in a pretty high tax bracket.

    You can’t just say, “See, those doctors in Germany get all those cool bennies plus they get $60,000 per year free and clear.” They don’t. If I have any German readers who would like to share with us how much, if any, tax such an individual would pay it would be edifying.

    The income tax in the United States on a salary of $240,000 is about $60,000. Add about $6000 for Social Security and let’s just say that without any help from your sly accountant you would expect to pay around $70,000 in tax (It’s going to be less because of deductions and legitimate tactics to lower one’s tax bite). Let’s just add my debt service as a “tax” which is going to be about 1500 a month for the rest of my friggin’ life so that’s about $90,000 total. Of course, I consolidated at such a low fixed interest rate that if we have a good bout of inflation for a few years it will effectively wipe out most of my debt.

    A lot of money but that still leaves you with a hell of lot more disposable income than a German physician who may, despite all the freebies, only be left with $30,000 or so in disposable income.

    It’s no contest. I betcha’ my attendings live in much nicer houses, drive much nicer cars, and generally have a much higher material standard of living than their European counterparts. Whether material standard of living is important or not is another question. American doctors also work a lot harder than their cousins in the Freeloader Kingdoms across the water. But working hard is part of our national character…just something that most of us do.

  19. Working hard is part of our national character? PLEASE. Tell that to the Chinese.

    Is that why we are fat, drive huge cars, and go to war with a purportedly idealistic purpose and completely fuck up?

    Is that why I haven’t seen a thin cop in years and they keep shooting people dead in their cars in my state? They sure are working hard, those cops. Easier to kill people than aim at their tires.

    Is that why, in spite of all the evidence,
    including loss of IQ, moms still are sticking bottles in the mouths of newborns? And we have the lowest breastfeeding rate in the WORLD? Because said moms and their associated pathetically-passive-on-the-subject health care providers work hard? Hey panda, I bet your hospital gives out giftie bags to new moms from the formula companies, am I right?

    Brandon Mayfield got put in jail because our forensics people, in spite of being warned by the Spanish forensics people, couldn’t recognize the madrid bomber’s fingerprints were a complete non-match. Was that because they worked so fucking hard?

    And don’t get me talking about the teaching profession and their union. They work so hard, those teachers. 58% of the middleschoolers in my state don’t pass reading.

    Only so many generalities I can handle, sorry.

  20. Breastfeeding is over-rated. My wife breast fed our first three. We’re bottle-feeding this one. No appreciable difference except the new baby sleeps better than any of the other three ever did.

    Don’t be a breast Nazi. Not every woman can breast feed her children. It’s particularly difficult for working mothers who may not want to hook themselves up the milking machine.

    I recall when I was at Duke on OB several of the patients implored me not to let the lactation consultants into their rooms because they didn’t want to breast feed and didn’t want to be strong-armed into it. For my part, I let women make up their own minds. I thought you folks were pro-choice?

    My only other comment is that you have to but scratch a liberal to reveal the raging core of anti-Americanism barely covered by a thin shell of civility. I merely commented that Americans work hard which has nothing to do with whether we are fat or thin and you exploded into an anti-American rage.

    I realize that dissent is purported to be the highest form of patriotism but the old-fashioned kind is pretty good, too.

  21. Okay, here’s my pet peeve. And although I agree with you on some common sense issues, one thing you said bugs me no end. It was your sentence:

    “The level of involvement required to change bad habits is simply more than we will be able to fund. Every patient cannot have a dietician, a therapist, a substance abuse counselor, and a life coach.”

    I’m tired of hearing physicians complaining about patients not “taking personal responsibility” for their diseases and conditions. And here’s why:

    I don’t want a frigging life coach, therapist, dietician or whatever. (I used a substance abuse counselor once, but that was MY CHOICE.)

    I happen to believe that this is STILL a free country, and I don’t the Health Police nagging me about such American Freedoms as bad habit.

    Hey, CHEESE, SHRIMP, EGGS, and TWINKIES in certain quantities can be bad for people–and what if somebody told you that it was “irresponsibile” for you to eat it because of your next labwork and weigh-in?

    I’m sorry, but this is America and I have a right to my bad habits.

    As for how this all relates to the medical system and the arguments on physicians not getting paid for their labor, the unviversal health argument, the clogging of ER’s and the overworking of ER staff—I do sympathize with those issues. But, if it’s going to cause a person to be so angry all the time that they are literally stressed out 24/7—

    then follow your own advice, TAKE PERSONAL RESPONSIBILITY, and go see:

    1. A counselor (to discuss a better career option for your stress level);
    2. A lifecoach;
    3. An accountant;
    4. And a therapist to see the root of your anger.

    And believe it or not, I really don’t mean to be ugly by saying all this, but goddang, you are NOT in the military anymore and can’t order people around, ya know?…

  22. Actually, I’m a liberal but I also accept that in general American workers produce 33% more per hour worked than our European friends. And work more hours on average. Of course, this is an average. For expample, we’re on par with German workers per hour, though we work more hours per day and far more days per year.

    It makes no sense to dispute economic data with a short laundry list of individual anecdotes, or antiwar statements. For example, despite the low pass rate of some middleschoolers, my friend who is a teacher butsts his butt for about 90 hours a week despite getting no appreciation from his school or his students’ parents. See what I did there? I completely disproved the statement that teachers are lazy by pointing out a single example of one who isn’t. It’s logically flawless.

    Equally, I wouldn’t generalize gaye’s statements to liberals in general. Most of the ones I know love America, and think it is, or could be, the greatest country on Earth. Just because we love it with open eyes and an appreciation of its faults as well as its strengths does not mean we’re anti-American. We recognize those faults because we want the US to do better, as we know it’s capable of, and we want others around the world to love it as much as we do. Although I’ll admit, there are a few exceptions among liberals, who I think generally do hate the US. Personally, I feel the Constitution is the greatest document ever written, and am proud to live in the only country founded on a collection of ideals. I think it’s possible to be openly patriotic and to engage in dissent at the same time.

  23. I am not a liberal, and this will be my last post, unless you grovel, mask in hand.

    I am a patriotic centrist, proud of my country, and I rooted long and hard to go to war to get rid of Saddam Hussein and make fascist Islamic fundamentalists take note that we were not going to tolerate any more Talibans. It was the leadership that was supposed to understand that we needed a 750,000 man force to do it successfully. Just because our leadership got us into Vietnam #2, I’m supposed to shut up?

    If you think patriotism involves keeping our lip buttoned and never talking about our very serious problems you are not only wrong, I invite you to consider yourself the very worst kind of patriot. The rest of the world is going to leave us in the dust, much sooner than you think, if we do not start dealing with them.

    And sorry, 7 points average IQ gain for 9 months of a breastmilk diet woud be a patriotic concern, not just a choicy thing. Please check out the 3000 patient Swedish study in JAMA before you talk about how well bottle-fed babies sleep at night.

  24. It is impossible to contstruct a valid study showing that breast feeding leads to higher IQs as there are so many confounding factors. In other words, mothers who breast feed may just be more involved with their kids and this leads to higher IQs. Breast feeding itself is incidental.

    Or it could just be that the study is full of shit. I might also point out that my breast feeding, over the last sixty years goes in and out of fashion. Is there a corresponding waxing and waning in SAT socres corresponding to various cohorts who were breast fed or not?

    Seven points IQ gain. What exactly does that mean anyways, how was it measured, who measured it, what stake did the researchers have in proving their hypothesis. It’s like asking the AAFP to prove that Family Medicine is the most important specialty. What else are they going to say?

  25. And I will delete any overtly political comments. You’ve managed to keep things on topic, let’s not blow it now. Personally, I’m sick of politics and have been since the 2004 election from which I am still post-ictal.

  26. BHRN, my post went straight over your head and, as is common, you are reading my article through the lenses of your own bias. I am advocating not telling people what to do, not the converse. Was that not clear? Letting people make and be responsible for their own choices is the exact opposite of telling them what to do. In fact, I am probably the one guy in the medical profession who wants to get involved in his patient’s lives the least.

    Go back and re-read, please.

  27. How did we get from discussing the salaries of docs in Europe to the benefits of breastfeeding?
    Anyway, I am glad that you are happy with your income PB, but the point of my comment was that in spite of their low salaries, most docs in the first world countries of Europe (except the UK) are satisfied. I have yet to hear the French, Dutch, or German docs whining about the “opportunity costs” of going to med school or the amount of their student debt. We just have different expectations.
    In the Netherlands, once you’ve passed certain academic standards, acceptance into medical school is determined partly by a lottery system, A LOTTERY SYSTEM! Imagine ever doing that here. Oh, and they don’t have much malpractice over there either.
    Lastly, I will add that in spite of all our hard work, the US still has worse public health parameters compared to the developed European nations and Japan (for example: Newborn death rates, see and our health care system costs the most.

  28. Whoa. Considering opportunity cost is not “whining.” It’s just part of life in the Big City and part of the hurly-burly, broad-shouldered capitalistic way of life where people may have expectations towards which they work.

    Being decisive is important but as the decision to go to medical school is not exactly something you have to make in a split-second, to not consider the pros and cons would be inconceivable.

    Same with selecting a residency where salary is an important consideration.

  29. I’m sorry, who doesn’t get a study of 3000 swedes which shows a marked decrease in IQ associated with formula feeding for the first nine months of life? If you should READ THE STUDY, you will find that very prolonged breastfeeding is associated with a decline in IQ from peak, but such subjects still have IQs above that of formula-fed subjects.
    Conclusion-nutrition is the big player, not maternal-infant interaction.

    Confounding factors, well, after 12 years in urgent care practice, I can tell you that I can usually enter the room with a child under the age of one year and know about their early diet. They look healthier, and yes, more intelligent and better adjusted, when they have been spared a formula diet.
    In my experience it is also almost non-existent to see a kid with recurring supperative OM requiring tubes who has not been formula fed.

    Anyway, why do european doctors matter anyway?
    Well, they do studies like the one we are arguing about right now. Shows they have some life left.

  30. Two of my children had OM requiring PETs and we were card-carrying members of the La Leche League. My new daughter has never seen a breast in her life and she is as healthy as a horse.

    So much for anecdotal evidence.

    Your study, I repeat, is meaningless unless you can correct for confounding factors of which there are thousands. And to say that maternal (and paternal) interaction with a child if not the big player in increased IQ is to sort of throw out common sense. All you have to do is see who breast feeds and who doesn’t and there’s your explanation right there. Kids are not more intelligent because mom breast feeds, rather mothers who are smarter and more involved (generally) with their kids also happen to breast feed. A relationship does not imply causality. The rooster crows every morning before the sunrise but it doesn’t mean he’s causing the sunrise.

    But the IQ thing is hokey anyways.

  31. I read your post adequately and nothing flew over my head. And yes, I am biased, as are you and everybody else in the world. (There are few “true” neutral people if you studied sociology.)

    Although you say you are “advocating” not telling people what to do, if one reads between the lines of your posts (or sometimes the outright statements), you come off as thought you ARE criticizing patients for not doing as you think they should.

    I know that you have stated that you “eat your critics for lunch” but that doesn’t work with me. I am not cowed, shamed, nor intimidated by blunt come-backs as I enjoy debating with people and don’t mind when they wholeheartedly disagree with me.

    In fact, I feel like I am the one who can “eat people for lunch” if you must know the truth, heh!

    Be that as itmay, I simply state my opinion and I truly mean nothing personal or “mean” by it. I enjoy your rantings as I enjoy your humor.

    And…..I’m doing precisely WHAT you enjoy—debating with you. If you didn’t want such debate, you wouldn’t put out what you consider “controversial” posts.

  32. In truth, I don’t know whether you were agreeing or disagreeing with me. You seem to agree that providing lifestyle coaches for all is a bad idea so, if your debating tactic is to agree with me…well, it’s pretty subtle.

    As for ED overcrowding, on one level it has no impact on me except that I will have to work hard for the whole shift. Oh wait, I already do that for minimum wage so I have no place to go but up.

    I also confess that I am alarmed that a call for personal responsibility should be considered controversial. Good Lord. When did that happen?

  33. The satisfied German doctors are fleeing the country in droves thanks to new rules that brought a salary decline of over 50% in the last few years.

  34. good God panda, please come and work for us when you finish. or go into politics. you will fail of course, as no one gets elected anymore calling for more personal responsibility, and that may be the death of this nation. it’s enough to make one want to build the compound in montana with the bomb shelter and the stockpiles of food. oh wait, have to consider i’m post three overnights in the ED… will think on it again tomorrow.

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