Kabuki Medicine and other Wonderful Tales

Kabuki Medicine

In one month I have had Mary as a patient four times. I have also noticed her roaming restlessly through the department on days when some other resident had the bad luck to pick up her chart. I would not be exaggerating if I said that she has been a patient in our department thirty times this year and the Lord only knows how many times at other Emergency rooms in the area. She is a huge consumer of emergency services and no one dares tell her to pound sand when she presents with one bogus complaint or another because one day, after crying wolf for her whole life, she is really going to be sick and if she dies the usual compassion fascists will descend on us like self-righteous harpies.

Thus do we regularly ignore common sense and, putting on our best kabuki faces, take every episode of chest pain, abdominal pain, shortness of breath, and near-syncope completely seriously pretending that we have not spent hundreds of thousands of the taxpayer’s dollars ruling out everything except drug addiction. It would be more cost effective if we just gave her perscriptions for all the oxycontin she wanted provided she limited her visits to once a month. Instead we enact the the traditional Kabuki drama where she assumes the role of a patient and we pretend to be her doctors. We stamp and posture, reciting our ritualistic lines while she demurely assumes the character of someone we actually can treat. Five acts later we discharge her, plus or minus a six-pack of vicodin, depending on how badly we want to get her out of the department.
File this under getting what you pay for. Putting asided the usual policy wonkery, the real problem of American medical care is the complete absence of common sense. Mary is not unique. She is just a very visible symbol of a society that is ridiculously risk averse and consequently ridiculoulsy over-doctored. In a perfect world, someone would meet her at the door and say, “No. You are not getting drugs here.” If she departed chastened from our door and died…oh, let’s just say from a perforated bowel… a reasonable jury, assuming the case ever went to trial, would decide that it was a darn shame but understandable given her pattern of abusing emergency services.

Of course this would never happen. In the real world we are cautious to the point of foolishness, at least if we equate foolishness with a cavalier disregard for money.
Consider, as one example, the typical cardiac work-up and the vast sums of money wasted every year on diagnostic testing and empiric treatment of patients with ridiculously low pre-test probabilities of being sick. (In other words, they are not sick.) A young male with no risk factors for heart disease should not need a complete cardiac work-up when he presents with chest discomfort as it is almost certainly going to end up being musculoskeletal pain, reflux, or anxiety. And yet the patient inevitably gets the whole enchilada including an expensive stress test and occasionally an admission if he is deemed to be unrealiable for follow up (because if he is told to return in the morning for his stress test, forgets, and dies three years later it is our fault). Now, it may come to pass that one day, out of ten thousand thirty-year-old otherwise healthy men you will isolate the one who does, in fact, have early coronary artery disease…but then you probably would have picked him out just from the history and review of systems. I don’t deny that if I were that one guy I’d be pretty happy that our system is structured to spend billions protecting against lightning strikes but the fact remains that we are spending billions with a very little to show for it in actual treatment or prevention of morbidity.

My point? I am getting tired of saying it and I will soon stop. Because of the highly litigious nature of American society, there is no incentive to exercise common sense. In fact, there is a perverse incentive to spend money like drunken Marines in a brothel because there is no allowance in American medicine for mistakes. The standard of care has become absolute zero-defect which costs money…but the key is that our system is so adept at shifting costs that it always appears to be somebody else’s money.

Potemkin Medical Care
Cuban health care is so good that thousands of Americans risk their lives every year on flimsy boats and makeshift rafts in a desperate attempt to make it across the shark-infested waters of the Straits of Florida. Many perish in the endeavor and the 90-mile strait is littered with the floating corpses of uninsured Americans, many still attached to their now empty home oxygen cyliinders.

Ha ha. No, not really. Still, as the idee fixe of the pseudo-intelligentsia is the efficiency and general superiority of Cuban health care it is only a matter of time. We’ve all heard the mantra. The Cubans, it seems, spend a twentieth per capita of what we spend on health care but, mirabile dictu, have better outcomes and better access to medical care. Michael Moore, a man who knows as much about medicine as I know about making documentary films (i.e. nothing), has even made a movie based on this premise.
Leaving aside the fact that Cuba is a Soviet-style dictatorship where the official statistics are manipulated to show the Dear Leader in the best possible light, ignoring for the moment that Cuba has the usual three-tier medical system of every worker’s paradise (one for the apparatchicks, one for the proles, and a Potemkin hospital or two for the tourists), and even forgetting the inexplicable love of the American left for a dictator and a society from which people are willing to risk death fleeing…leaving aside all of this I just want to know why, in a society with a per capita income of just 300 dollars per year they manage to spend so much money with so little to show for it.

The per capita income in the United States is about $40,000 per year or about 130 times that of a typical Cuban. Cuban doctors make about three hundred dollars per year or about half of what the typical American family, even those in the dependocracy, spend for cable television. Cuban nurses probably make what my young children get as an allowance. Since labor costs are the biggest expense in health care both here and in Cuba, I just want to know why the Cubans are spending so much money on health care and still have a life expectancy less than the United States. Something doesn’t add up. Cuba is 130 times poorer than the United States and yet, in relative terms spends five times as much on health care.

Oh my long-suffering readers, do not yearn for Cuban-style medical care in the hopes that it will be cheap. It’s cheap for Cubans because Cuba is a third world country where everyone is poor. In Cuba a doctor might be willing to work for fifty bucks a month but in the United States, any enterprising teenager can make 20 times that amount working as a taco jockey. In other words, unless you plan on making everyone poor, good luck getting people to work at the hospital wiping yer’ grannies ass or coming at night to admit a patient for the kind of wages it would require to Cubanize American medicine.

48 thoughts on “Kabuki Medicine and other Wonderful Tales

  1. Why the public fails to realize this is truly beyond me. Instead we are subjected to idiocy like Sicko and the idiotic WSJ editorial on how fee for service is the root of all evil.

    Someone needs to add up the Medicare billing on one of these patients that goes over a million. Anonymize it, write an article about it, and try and get it into the press. Maybe then people will start to realize that the reason their health insurance premiums are $2k a month is that SHE USED FORTY ONE YEARS OF YOUR PREMIUM ON WORTHLESS TESTS. Ye Gods, the inmates truly have the asylum.

  2. Castro, who no doubt gets the best Cuban medicine has to offer, had to bring in a surgeon from Spain to save his sorry ass. I hear this “Cuban medicine is the best in the world” crap from my classmates all the time. It makes me want to scrape my fingernails on a blackboard for relief.

  3. Amen.

    I always get exited when I hear about tort reform but am always disapointed. After witnessing the jury system in a case in which I was an expert for the PLAINTIFF I don’t know what to think anymore. In this particular case the doctor was clearly a buffoon and the plaintiff was badly injured as a result. The jury found for the doctor on a retrial after the first jury found for the doctor and the judge threw out the verdict as being STUPID. WTF?

    Perhaps you can tell us sometime what your job was for the corps. I’m a vet and worked closely with the green side. Love your blog.

  4. It still amazes me that even smart, educated people can be so taken in by statistics in a vacuum. When I talk to people who are for the single payer system and ask them if they would be willing to be put on a waiting list for months at a time for a procedure, they’re outraged. Of course they wouldn’t, they deserve the best healthcare when they want it. Yet they continue to spout statistics about per capita healthcare spending in Canada and England. It’s just insane.

  5. It’s just a matter of time until someone chimes in with the life expectancy/infant mortality statistics of the US v UK/Germany/France etc. (parameters that have more to do with a working sewage system/decent nutrition than medicine, barring immunizations.)

  6. I think if you want the curb the weekly drug seekers, some state needs to make a law saying if you have more than a 30k of unpaid ER bills (or any arbitrary amount) in a calender year and your vital signs are normal, you CAN be turned away.

  7. “musculoskeletal pain, reflux, or anxiety” Or farking pericarditis, which, but for the “unecessary workup” was going to kill my husband.

    And you know what? Make the war on drugs go away, make narcotics more readily available, and patients who want them won’t come to the ER to fake something to get them.

    I’d rather have you try to bring OD’s back to life than let someone wallow in their own vomited blood in screaming agony in order to avoid giving them pain relief you disapprove of.

    (What on Earth are you talking about? I can tell an acute abdomen from a tummy ache. And I am all for relief of pain, I just don’t want to be the patient’s recreational drug supplier.  You have also completely missed the point.  We can have a system that demands zero defects and is unwilling to take the slightest risk, no matter how small, of something being missed…or we can have an efficient, inexpensive system but we can’t have both.  As long as you’re willing to foot the bill for Mary’s emergency care (because somebody has to staff the ED and run the labs) then you shouldn’t necessarily be complaining about how expensive yer’ stinking medical care is.  As another commentator pointed out, people like Mary who are not uncommon at all use up, in one month, the health care premiums of a whole busload of relatively healthy people…and for what?  Nothing.  -PB)

  8. You predicted my afternoon patient. 20 yo male athlete, chest pain, urgent care center dx musculoskelatal pain. Family member works in the stress test lab at hospital sooooo -> ER visit. Same diagnosis. My office same diagnosis met with demand for stress test “just to be sure” based on family member expertise. I forgot to ask if they want fries with that stress test. What am I doing here?

  9. “musculoskeletal pain, reflux, or anxiety” Or farking pericarditis, which, but for the “unecessary workup” was going to kill my husband.

    Assuming you’re not referring to constrictive pericarditis, his presenting history likely would have been suspicious for acute pericarditis and he probably got an EKG which confirmed the diagnosis (along with the physical exam) by having diffuse S-T elevation and P-R depression. As there are many causes (although viral is the most common) additional lab/imaging would’ve have been dictated by the history and physical.

    Not an unnecessary work-up and not really what PB was referring to.

  10. Oy.

    People keep urging me, “Why didn’t you go to medical school?” and “You are amazing, you really should become a doctor.”. This entry reminds me that I am already jaded enough with life.

    Thank you!

    (You see, I don’t understand this.  Every time I point out that the world, including the medical profession, is imperfect I get accused of being jaded.  I am a lot of things but jaded is not one of them unless disliking my very first drug-seeker without having to have grown weary of them counts for jaded.-PB) 

  11. To NoAcuteDistress:

    Are you talking to me? (In a Robert DeNiro voice.)

    As a veteran ER nurse, I saw so many of the type of patients that Panda describes in this post that they actually didn’t bother me anymore. In fact, the inevitability of seeing them became a routine that I finally accepted as part of ER life. I lost my irritability with them.

    As for “compassion”, I did have a little for them (withdrawal can be a b__tch) but a lot more for the overworked staff. So this is how one of my Triage interviews went with the worst offenders:

    “Hey there, Joe Blow. You here for back pain again? Oh, I see. Tsk tsk, that back IS bad, isn’t it? Well, let me take your vitals and I’ll get you to the back as soon as I can. Honey, you know you’ll have to wait, right? Hey, tonight’s Dr. So-and-so! Maybe you’ll get lucky and he’ll give you some vicodin! Talk at ya later, ‘tater.”

    I would even ask IV drug abusers to tell me up front which was the “best” vein so that I wouldn’t waste my time on the crummy ones. They always obliged and I saved a lot of dang time and got my IV in quickly. Again–I was dead honest in a friendly way and it was appreciated. They know the score.

    Okay, then the doc would examine them and (if he was a tired veteran) then simply give them a little bit of whatever it was they wanted—- and we got rid of them quickly. Problem solved, bed empty. Next?


    One night an angry-type doc was doing a resentful chest pain work-up on a well-known frequent flyer. Finished all his tests and was about to dismiss her with a pain pill RX, diagnosis “back pain”. And I just happened to check her EKG rhythm before discharging her. I noticed the ST segment slightly….ever so slightly….elevated.

    It was change of shift and he didn’t want to hear it. So I told the next guy who was following him. He looked.

    She was then transferred to the heart hospital. She was having an MI.

    (And I’m stunned that you called me a Nazi. Really? That’s a rather silly thing to say about a nurse. I never sent anyone to a gas oven or firing squad in my life. Nor am I prejudiced against Jews, mentally retarded people, gays, gypsies or anybody else. You need to read your Webster’s definitions before you call names, chump.)

  12. I also want to point out something that should be obvious, so obvious that you will slap your head sheepishly when you hear it and say, “Duh.”

    Drug addiction, homelessness, and public intoxication are not emergencies and are not strictly speaking even medical problems that can be addressed by physicians. People just come in with these problems, or are brought in, because the Emergency Department is the only representative of The Man that is open at 2AM and people expect The Man to take care of them.

    So you get a drug addict or a homeless guy as a patient and you fight the urge to ask them, “What exactly do you think I can do to change the trajectory of your life?”

    It ain’t my job. Plain and simple. You can make it my job, of course, but the patient flow is going to slow to a crawl as we attempt to solve the almost unsolvable personal problems of our patients. And why, may I ask, should this task be assigned to doctors, nurses, or anybody at all?

  13. “(You see, I don’t understand this. Every time I point out that the world, including the medical profession, is imperfect I get accused of being jaded. I am a lot of things but jaded is not one of them unless disliking my very first drug-seeker without having to have grown weary of them counts for jaded.-PB)”

    I am not so much accusing YOU of being jaded, as I am observing that in that environment I surely would. 😉

  14. I think a certain “veteran miss. bad ass” nurse needs some therapy if said nurse is deluded into thinking anybody cares about what she’s saying. Hell I just skip past her posts since they don’t contain anything intelligent; I don’t see why you guys don’t just do the same. The sooner you ignore an immature child that cries for attention, the sooner that child will grow the fuck up or at least leave you the hell alone.

    The main problem with the cost of health care is because it seems like we’re always going to have dumbasses with the “jackpot” mentality, dumbasses who think being drunk or having a stubbed toe warrants a trip to the ER, etc…there’s such flagrant abuse of the EMS system that it’s unprecedented. You can call 9-1-1 if there’s somewhere near the hospital you want to go and just take off once the ambulance gets to the hospital. It’s been done plenty of times and nobody even thinks to charge them with crimes. I hear it /is/ illegal in one or two states, but that’s hardly enough to fix the problem.

    De-criminalizing drugs /would/ solve the problem of the junkies, but it wouldn’t fix the idiots and various other assholes who abuse the EMS system, so a better alternative would be to make it a felony to abuse the EMS system (and of course it’d have to be an /obvious/ abuse of the system, such as someone doing the taxi shit or a junkie coming in for drugs who fails a piss test horribly). If people start getting slapped as felons for wasting everyone’s time and money, maybe it would help curb the problem.

  15. Legalizing recreational opiate/opioid usage might reduce dependence on the ER for those things, but in the event they were legal, they would cost money. A drug seeker can present with a made-up complaint and get the same drugs for free. Why buy?

  16. “De-criminalizing drugs /would/ solve the problem of the junkies”

    The problem is that junkies and every other deadbeat-ness have been medicalized.

    Once the pseudo-intellectuals succeeded in making addiction a medical problem then of course the junkies head for the ER.

    Every problem known to man is now a medical problem and there’s a drug to cure it. Which only doctors can prescribe.

    Doctors prove they are superior to the rest of us (years of training, etc, etc), so of course they become the daddies/mommies to turn to when life gets “too hard”.

    And we all know how grateful and compliant one’s children are, especially in adolescence.

  17. Why EMT Tim—such “profound” wisdom coming from a 23 year old EMT.

    (Said with heavy sarcasm, eyes rolling, and laughing hysterically at his ridiculous notion of “criminalizing” a person calling for an ambulance if they are what he considers a “a dumbass with jackpot mentality”.)

    EMT’s, if I remember correctly, have little more ability to medically “assess” an ill patient than an ER tech. In my state they can’t do Code Blues nor have I ever seen one who could read a 12-lead—-so EMT Tim most certainly hasn’t got the necessary training to determine “real” or “unreal” emergencies by any means!

    Oh, EMT Tim: How well I remember your type in the ER’s I worked. We ER nurses and docs didn’t respect your ilk much because your cocky, young arrogance was a detriment to “the scene”—-your reckless and overly confident type couldn’t give a decent “report” and we just flat out had no use for mouthy, swaggering young kids who wouldn’t know their way around a crash cart if their lives depended on it. (Or their patient’s….)

    So don’t even TALK to someone like me until you’re a PARAMEDIC with a few more years on the street and some REAL understanding of what you speak…

    (Did you even GO to college?)

  18. I used you really enjoy your entries. Now, your entries have painted a picture of a profligate society with abusing patients. Obviously, these patients do exist. But what about other patients? The patients who actually need the help? Can you post something that is more heart-warming? After reading like… the last 5 entries bashing Healthcare systems… I’m started to feel nauseated from the negativeness. Can you post something like… what keeps you sane in Emergency Medicine? Or why you chose to do that in the first place? Thanks man.

  19. I could tell a great story that has kept me sane for years.

    Intern days, surgery rotation, patient shows up, had gotten carried away with a vibrator which had migrated rather inward into GI tract.

    Patient taken to a procedurs suite where he is sedated and veteran surgeon attempts to remove item with a snagger device under camera surveillance. Can’t.

    I ask surgeon if I can try. Told him I had spent a lot of time with brood mares in difficulty. He nods. (this was a great guy, still smoked in the dr’s lounge,etc)

    I ask nurse to use pressure with both palms against lower abdominal wall, reach in slowly, fist and all, and extract penile-shaped vibrator, 12 inches long, still vibrating.

    Sorry, couldn’t resist.

    C’mon, tell us some better stories.

  20. Well CC and Peggy, you guys do have points, and as far as “addiction” being a medical problem, you won’t get any arguments from me as to it being a bunch of bullshit…addiction isn’t a medical problem, it’s a personal choice. Granted a shitty personal choice, but a personal choice nonetheless.

    Considering how cheap people are, yeah they probably would still go to the ER if drugs were legal, just so they didn’t have to pay for them. Gah. Like I said, we need to just start making it illegal for people to abuse the system and waste its resources so others have to pay more to get the same care.

    Ah well, I have nothing else I can think of to say right now, so I’ll just nod to Prowler. 😛 I doubt she even has a R.N., or for that matter, even a Trash Management Certificate. Meh, not wasting my time at least.

  21. Love the blog.

    This time, though, I’m not sure where you’re getting your figures from. I did some checking:

    -Per Capita Income in Cuba is closer to 2 and 3 thousand, not hundred

    -According to the World Health Organization, Cuba’s total expenditure on health is about 6.3% of their GDP: approx $229 per capita. By comparison, the USA spends 15.4% of the GDP on health, which adds up to around $6k per capita. You write that Cuba spends 5 times as much on healthcare as the USA, but the numbers seem to contradict. The USA clearly spends much more.

    -Also available through the WHO is information that seems to indicate that life expectancies between the USA and Cuba are more or less the same. Certainly not different enough to serve as a point of argument.

    As I’m sure you are aware, the doctor/patient ratio in Cuba is one of the best in the world (second best actually), although you are correct in that those doctors are paid pretty poor wages. It makes one wonder why such a disproportionate number of doctors would submit themselves to such a system. Low doctor pay has been consistently cited as one of the major causes of concern in Cuban medicine, but your entry here seems to do little to highlight exactly how this actually plays out for the healthcare consumer. Given that the life expectancies seem to be similar, exactly what faults are you pointing out here?

  22. Love the post. My favorite line: “Because of the highly litigious nature of American society, there is no incentive to exercise common sense.” I did part of my training in England, and it was amazing: the doctors didn’t order tests just for the sake of covering their asses. And when it was time, the patients were actually allowed to die.

  23. Bravo Panda! Excellent post!

    I wholeheartedly agree regarding our overly litigious society and other points as well.

    I especially appreciated the following: “Cuban health care is so good that thousands of Americans risk their lives every year on flimsy boats and makeshift rafts in a desperate attempt to make it across the shark-infested waters of the Straits of Florida. Many perish in the endeavor and the 90-mile strait is littered with the floating corpses of uninsured Americans, many still attached to their now empty home oxygen cyliinders.” Amusing to read – your point is well taken.

    Tragically sad for the Cubans that do risk their lives and that of their families and leaving all that is familiar behind in hopes of better health care and a better life. If Michael Moore wants to make comparisons of health care in free countries fine – BUT puhlease…with a dictatorship? Yikes!

  24. People do not flee Cuba in hopes of better health care. Most people don’t even think about health care when they make big decisions, witness the vast legions of uninsured Americans who could afford insurance or to pay out of pocket for most of their routine health care but decide that if they really need anything they can always get it for free at the local emergency room. Thus has EMTALA created a perverse disincentive for people not to even buy a major medical policy.

    On a related note, I read something by someone who believed that it is only the wonderful health care that the Cubans enjoy which has kept them from revolting.

    Not to mention the secret police, of course, and other organs of repression alive and well in Cuba.

  25. I’ve never liked Michael Moore because I’m a bleeding heart, ultra-patriotic, diplomatic brat—and I also think he’s an idiot.

    But… I DID think that this article (in this morning’s MSNBC online news) was spot on—hit the nail on the head—about just who ARE “the ones who don’t want socialized health care” and WHY they don’t want it:


    I believe that the whole healthcare argument in America just screams that tattered, whispered phrase: “Follow the money”….

    (So?  Is this a deep dark secret or a crisis that people make money?  The sad fact is that except for the political will to do it, some of the structural problems of medicine could be easily fixed by continuing to provide charity care, slapping down the predatory legal profession that wages war on medicine, and allowing more competition and free markets into the system, not less.  The fact that money is made bothers me not a bit.  The alternative is to have no money made and no incentive for anybody to do anything.  The problem is that all of you hysterical folks want to build a wall between the medical industry and the rest of the economy.  -PB) 

  26. Hi Panda – I stand corrected – Thank you. 🙂

    Actually – I did not mean to say they were leaving Cuba for better health care and I didn’t say that when I commented about Cubans risking their lives to get to this country when I posted comments elsewhere. Momentary glitch. 🙂

    You know, it might be interesting if Moore interviewed some of the American Cubans who did manage to get out of their country.

    I think your last sentence says it all.

  27. (Panda–you bug me.)


    I DID live in Miami and worked at Mercy Hospital, Coconut Grove, in the CCU/Neuro ICU. (And I was part of the Code Team.) Most of the doctors there WERE Cuban—and they said that they wouldn’t go back to Cuba if there were golden dolphins in the IV bags. I had 80% Cuban patients. A nurse had to speak Spanish to work there. The Cuban docs spoke in Spanish the whole day and called me the “rubia” because I was blonde.

    And your point?

  28. You spout plenty of platitudes, but not much analysis. You parrot classic health care debate bromides about how great health care would be if it were a totally free market, presumably without Medicare, relying on simple charity. However your diatribe about the Hippocratic Oath suggests you wouldn’t be the doctor doing the charity work. Given the motivation of for-profit work (money) one will always make more with normal fee procedures than by recouping costs from charity work through tax-deductions. Scraping a tax return just doesn’t pay as well, and few would do it except for the few truly saintly docs out there. So please, tell us your theory about how it would occur?

    Moving down the supply chain, what of insurance companies? Insurance companies cannot supply sufficient health payments for their members while at the same time trying to maximize profits, those are mutually exclusive goals. That is why insurance companies go that extra step to make utilization of their terms by their members difficult and delay payments to providers who intercede for them. Profit motivation in that industry runs counter both to efficiency AND adequate care, and competition actually worsens that because there is no sound basis for patients to evaluate a complicated product like health insurance since one needs a bit of medical and legal knowledge. Insurance companies know this is a sucker market, so competition amongst them simply degenerates into who can screw their members more than the other.

    Another problem which is key to why US health care costs are rising faster than the rest of the world is the growing income inequality here. Doctors have been and want to continue to be in the upper income slice which is rising leaps and bounds faster than the lower 4 quintiles. By definition every year, just through this mechanism alone, increasing proportions of the population can no longer afford insurance. This is one of the reasons employer-based coverage has been shrinking over the last few years, plans sometimes outright dropped, and tax deductions for premiums implemented for individuals. Perhaps that is also one of the reasons why Businessweek today reported only 40% of Americans are satisfied with our health care system, while 65% of French say they are satisfied with their health care system.

    Limiting malpractice costs will not likely lower health care costs on average since very rarely do windfalls ever get passed on to consumers, it is just pocketed. Such a windfall may briefly delay the continued rise in health care costs, until it is absorbed, but the underlying problem of rising income inequality is still there. Panda, you are long on gripes but short on ideas. If our system is going to work under the completely free market model, please suggest how?

  29. It just hit me….it just hit me right square in the head why I “fight” so much over here.

    I’m…..where…warriors be. Panda is a WARRIOR.

    But, since Max has put it much more eloquently than I ever could…..I will declare this:

    I lay down my own sword.

    Panda may be a Sith…and I am a Jedi Knight….

    But if he strikes me down, then I will only become stronger within The Force…

    The Battle Has Begun.

    (Look, it’s just the internet.  I’m not a warrior.  I have a real job.  I don’t understand why you keep sending vicious email enjoining me to “shut the fuck up,” accusing me of blocking your ISP address -something I wouldn’t do even if I knew how-and commenting on my blog. If it is so painful for you to read my blog why do you inflict it on yourself?  Read it.  Don’t read it.  Comment.  Don’t comment.  I don’t care that much either way.-PB) 

  30. Competition in certain areas of health care is alive and well, and improves service for the consumer (consider cosmetic procedures and corrective opthalmologic procedures.) In primary care, too, urgent care centers compete with the ER/PCPs, claiming to provide services for less and in less time, at more convenient hours.
    Part of the problem is the difficulty in negotiating prices for many medical services. Since so much is covered by insurance (private and public), prices are essentially set. Procedure X costs price Y, because that’s how much Medicare/Highmark reimburses. Negotiating/discounting is not an option.

  31. the cubans export doctors. they are not top class, but close enough. in my country, i think they are the reason our health care has not totally collapsed. not to sound too cliche, but some of my best friends are cuban doctors.

  32. Doctors in many third world countries, as far as their training is concerned, are the equivalent of our PAs and NPs. Not busting on them but if you cut out all of the critical care, the medical and surgical sub-specialties, as well as the vast hordes of multiply comorbid patients which are routine for American doctors what are you really left with?

    Nothing, nothing but low-level primary care which can be handled by so-called “barefoot doctors” sent to the hinterlands.

  33. i know the ED is a busy place and all, but i think over time you’d save more time for yourself and everybody by actually adressing her problem rather than being just another mark she can play, or another drug dealer for her…

  34. Her problems cannot be addressed or solved by any power on this earth unless she, herself, is motivated to change which she is most certainly not.


  35. I love reading your stuff. You have a great talent for writing about the absurdity of the self-righteous ninnyism that prevails in American public life. As a medical student, I wish some of my classmates would read some of your material. Sometimes I wonder why I am putting myself through all this. I must be a glutton for punishment.



  36. I do not know what good Vicodan is. I had it a few weeks ago for a bad tooth infection and extraction and I am still f’d over it. My intestines are still waking up and I only took two doses. Why do people like this junk? I read the Vicodan posts and double over. . .

    How does “Mary” get all the tests in the world when my rancher father had a stroke and, even though he rode with his doctor regularly, their attitude was, “He’s old and he will die anyway” as if he had not much time to live? (He held on for six months until I got down to tell him that I loved him. He died a few days later. Six hours before his stroke, he put his FOURTEEN horses to bed, had been training a few that day, had others working out– he sold his horses to celebrities and wives of celebrities and he was good.) His stroke was something that had they listened to my mom and given him medicine to counteract it within three hours that he would have had a much better chance of living.

    Good point about Cuba. My dad was on Medicare. No one realizes that in our country, after age 62, EVERYONE is on Medicare. It doesn’t cover a lot of life-saving treatments, and what it does, it’s not worth it for the hospitals to treat them and doctors are watched on who they give it to and how often and probably get into trouble like Charity Doc did. It’s probably a lot like Cuba.

    My mom is not suing– she is working with patient advocate groups right now and trying to wake up lawmakers about how badly MEdicare is working for seniors (maybe they are taking Vicodan.) She was anti-doctors until I sent her to your blog and a few others and she knows you are on her side.

    You don’t need to answer this about Mary getting all the treatment. I’m feeling blue right now– anniverary effect!

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