Hey Dr. Bear, you are something of a critic of the “old school.” What was wrong with the way doctors were trained in the past and why should we change things if the old ways have worked so well?
When I was a structural engineer, I had an old-school boss who had never quite made the philosophical jump into the computer era. Oh sure, he accepted that computers were essential to the business of engineering but he obviously longed for the Good Old Days when engineers made all their calcuations with a pencil and a slide rule. He often made us check our calculations by hand and barely tolerated the use of a calculator for this purpose. His contention was that engineers were better trained and more capable in the old days and that hand calculations gave one a better feel for the meaning of numbers. The Chrysler Building, he often pointed out, was built in a time when computers were unheard of and all the engineers had were their trusty slide rules and their tables of logarithms.
There is no doubt that the engineering profession is built upon the broad foundations laid by engineers of the past. Nor is there any doubt that a healthy respect for their accomplishments and a knowledge of the basic principles that they formulated is necessary for the education of an engineer. But the engineering profession has moved forward and while respect is necessary, mawkishly worshiping the old ways is impractical and counterproductive. Not only do we know more but new methods of design and analysis have made many of the old methods obsolete. Not to mention that certain economic realities dictate that we can no longer spend a day setting up the math to solve an engineering problem when we can have the result in five minutes using any number of structural analysis and design software packages.
That’s just the way things are. My boss used to insist that if we ever lost electrical power or found ourselves on a deserted island all of us new guys were screwed. The obvious flaw in that threat is that we’re not exactly going to be doing sophisticated engineering while waiting for rescue and if the apocalypse should come, we will be too busy scrounging canned goods and fighting flesh eating mutants to even think about breaking out the slide rule.
Now consider the practice of medicine, another profession which is supported on the broad shoulders of the past. Medicine underwent a revolution starting in the late nineteen-sixties going from a sedate, contemplative profession built on slowly acquired experience to the fast-paced goat-rodeo-cum-chinese-fire-drill it is today; a profession where there is barely time to examine a patient before he is fed into the patient processing plant which most hopitals have become. It is a fine thing to long for the Good Old Days when doctors spun their own urine (whatever that is) and did their own peripheral smears but those days are gone and, to paraphrase The Boss, they ain’t coming back. Likewise, our antiquated system of residency training, as it is was designed for the slow-paced hospitals of the past, is a poor fit for the way medicine is practiced today. In the old days, when patients were usually long-term boarders for whom nothing could really be done, a certain amount of leisure time was built into the system. This leisure time was filled with rounds, grand rounds, conferences, more rounds, spinning urine, making slides, lovingly writing extensive notes, and hour-long physical exams. Now that medicine has become something of a grind, while you could take thirty minutes for a detailed neurological exam to isolate a lesion to the left posterior globus palidus, you can instead send the patient for a CT and save yourself the carfare.
Which is what happens. You can no more practice medicine today like an old country doctor than you can design a skyscraper with a pencil and a slide rule.
What is the biggest problem facing American Medicine?
Let me tell you a story. The other day I had a patient who came to the Emergency Department in the early hours of the morning with a chief complaint of constipation for twelve hours and the subjective sensation of a “turd stuck up there.” “Surely there must be more to this complaint,” I thought to myself and launched into a careful history and physical exam to ellicit something, anything, that might kill the patient or cause him serious morbidity. Nothing. Zero. No abdominal pain. Passing gas. No vomitting or nausea. Appetite good. Abdomen non-tender. No fever. No nothing. There wasn’t even any stool in the vault when I finally did a digital rectal exam in the forlorn hope of finding blood, a mass, or just about anything to rekindle my faith in the basic intelligence of our patients.
Finally, more than a little annoyed I asked the patient what, exactly, he expected me to do for him.
.
“I need help taking a crap,” he said as he settled back into his bed.
I gave him a lecture on fiber, told him how to access his local Wal Mart, and sent him on his way.
In a perfect world, this patient wouldn’t have even got through the door. He would have been stopped cold by the triage nurse, rejected at the net, so to speak. I have no doubt that if this same patient had presented to an Emergency Department in France, he would have been subjected to the full brunt of Gallic derision. In the United States, the complete lack of common sense, a trait that has been beaten out of the medical profession by the depredations of the legal profession, ensures that this patient and many like him tie up Emergency Department beds and suck up finite medical resources, principal among these being the time of the physician and the nurse.
It’s not that one patient really has that much of an effect. We have the beds, after all, and the worst that happens is that others who are not acutely ill have to wait. But the over-utilization of the Emergency Department by patients who are not actually sick or have no discernable medical problems for which we can provide treatment forces us to maintain an expensive infrastructure many times the size of what would be required if we limited our attentions to patients with legitimate medical problems.
The consequences of ignoring common sense extend into all areas of medicine. Everything is not a medical problem, even things that are medical problems if you can get your mind around this concept. Knee pain, for example, that is the result of weighing 500 pounds cannot possibly be treated by a Family Physicians, an Orthopaedic Surgeon, an Internist, or an Emergency Medicine Physician. When you weigh a quarter of a ton you are just going to have knee pain. It is, however, the fear of being sued on one hand and the desire for a steady stream of paying customers on the other, that keeps the clinics and emergency departments full. Job security, no doubt, but I’d rather work in a rational system based on common sense than have that kind of artificial job security.
What do I think is the percentage of my patients who have no business getting through triage? It’s hard to say. We see our share of serious medical problems and the acutely ill. But thirty percent would not be an outrageous estimate. If you had a bad payer mix, that is, a high portion of uninsured patients, it would probably be cost-effective to have a physician, and not just any physician but the most experienced one in the department, running triage to quickly winnow the wheat from the chaff, the drug-seeking back pain from the aortic dissection, and the menstrual cramps from the ectopic pregnancy.
So it is the profound lack of common sense that is the biggest problem facing American Medicine. The effects of this lack of common sense, trying to practice zero-defect medicine among a terrifically unhealthy, mostly non-compliant, and litigation-happy patient population are legion and spread their costs and inefficiencies throughout the system. What is most paper-work, after all, other than an attempt to fend off predatory lawyers and their mostly ridiculous lawsuits? There’s a doctor shortage, apparently, but I notice that I spend more time on the patient’s paperwork than I do on the patient and as most of this contributes nothing to his care, imagine how many more patients could be seen or how much more time I could spend with a single patient if we somehow could kill all of the lawyers.
Not to mention the cost of unnecessary tests and treatments undertaken because the wages of intelligent inaction are ruinous while juries, as they are composed largely of people who can take two weeks off pretty much whenever they want, smile favorably on the physician who does something, anything, even if is pointless.
What’s the most ridiculous thing about your job?
Patient satisfaction surveys. Totally meaningless and generally not worth the price of printing them, especially in Emergency Medicine where the patient may rate his visit on the availibility of parking, the alacrity with which the nurse brought him a pillow, and anything other than the quality of his medical care. We saved his life but had to cut off his expensive jeans and it just left a bad taste in his mouth.
Consider a recent patient of mine who presented with diabetic ketoacidosis secondary to not taking her insulin as the price of it seriously ate into her crack cocaine money. We did the usual things, caring for her no differently than if she were our sister and after an hour or so of being grateful, she started to feel better and the complaints and abuse began. I have no doubt that upon her discharge, this polybabydadic mother of six, all in foster care, with no means and no intention of paying a dime for her medical care was presented a patient satisfaction survey courtesy of that modern devil, Press Ganey, and asked to rate her hospital experience. Now, why we should care about the opinion of a non-paying customer who is otherwise habitually to be found turning tricks in parked cars or passed-out drunk in an alley somewhere in the seedy side of town escapes me. What is she going to write that could possibly be of use?
“I’d like to see a better variety of free samiches.”
“More dilaudid, please.”
And yet I have no doubt that each of her complaints would be taken seriously by the shadow bureaucracy that exists to bedevil doctors and nurses. The ridiculous thing is the insistence that medicine is a customer-service business like any other when it is most certainly not. It is nothing like a business. First of all, the customer is not, repeat not, always right. We do not tailor our treatment to fit the patient’s expectations, rather they come to us with a medical problem and we tell them, whether it bothers them or not, what must be done to correct it.
There is also no such thing as a customer in the traditional sense. Most of my patients don’t pay a dime for their visit and don’t expect to either. Asking for their opinion is like asking a shoplifer what he thinks about the decor or the new security arrangements. Even those with that gigantic ponzi scheme otherwise known as health insurance have no idea how much things cost, don’t care anyways, and feel entitled to as much of the health care pie as they can stomach. If there was really a health care crisis, a crisis that is threatening to swamp the system, you’d think we would be trying to discourage customers, not encourage them.
You know, like how MacDonalds has uncomfortable seating to discourage loitering.
Panda, this essay was brilliant, absolutely brilliant. You are shaping at least one young, impressionable mind currently in medical school. Keep up the good work.
😎
Why doesn’t Press-Ganey mail the satisfaction survey to the patients AFTER they have paid their bill in full. This would be a reasonable compromise to assess satisfaction (whatever that is) in a set of patients who are actually desirable to the establishment (eg the ones that pay).
Bravo! I’m learning here, I’m learning here…
I love the old school dedication to the physical exam. When the old fossil is teaching you tactile fremitus he says, “well what are you going to do when the CT scanner is broken?”
“Ummm, I’m going to be distrustful of meaningless physical exam steps until they fix it…”
Pretty good. I think you’re a bit overboard on killing all of the lawyers. People do have rights, and a modicum of skill and professionalism is expected from people who have had 7-10 years of schooling — this is why Good Samaritan Laws don’t apply to healthcare professionals, you’re expected to do better than a bystander.
Also, you said that healthcare is “nothing like a business.” Which is completely untrue. ER is a bad vantage point to see that, but try looking at your cardiovascular or orthopedics service lines. Patient’s are consumers of healthcare (albeit victims of monopolies because nobody enforces anti-trust law anymore) – but they/their insurance are going to pay for your expertise (the same way you pay for a mechanics expertise to fix your car). And you are expected to do the job right and be congenial or you lose their business. Hospitals have high operating expenses and must be profitable to be able to afford departments that are necessary for JCAHO, but a money-suck (like ER). I agree with you that health-care is not like any other customer service business, in fact I’d say that health-care is the most screwed up business out there (largely because the people that run hospitals often know nothing about business/economics) plus the government screws with healthcare more than most industries.
“Now that medicine has become something of a grind, while you could take thirty minutes for a detailed neurological exam to isolate a lesion to the left posterior globus palidus, you can instead send the patient for a CT and save yourself the carfare.”
What’s wrong with medical training today? Here’s a good place to start. These young whippersnappers who order a $1000 CT (which may or may not show the globus pallidus lesion, depending on what it is) *instead* of actually examining the patient.
And the cost is only a small part of the problem with this approach.
(There is not a neurosurgeon alive who will operate on a patient’s brain (on the occasions when something can be done, I mean) without an imaging study of some kind. So I can take my leisurely time figuring it out but as I am going to get the CT anyways it is not an efficient use of a physician’s time. Imaging of the head is the standard of care.-PB)
Interestingly, most of the problems you complain of come not from a dearth of common sense, but rather from the way physicians are paid. You even unwittingly mention it when you talk about how medicine was in the 60s.
Then physicians made their Faustian bargain with the government to get healthcare funded by govt.
Your claim about juries is laughable to anyone who has ever served on one. You don’t get excused from jury duty simply because you have a job. It would be interesting to see what would happen if physicians would take some responsibility for their situation rather than blaming it on the patients, lawyers, govt. and everyone else they can think of.
Matt, why shouldn’t physicians blame their patients?
I just started my prelim year in medicine (and thank God it’s only for one year) and I am already amazed by the number of manipulative noncompiant demanding and irresponsible patients that hit the ER door– not to mention the annoying Spanish-speaking only patients some of whom have lived in this country more than 20 and 30 years and don’t speak a goddamn word of English.
To illustrate my point, there are the drug-seeking addicts who decide to show up to the ER at (of all times) 2:00AM complaining of chest pain so they can get their shot of morphine (after claiming nitroglycerin doesn’t work, of course!) and if they are lucky, maybe a bit of their beloved dilaudid. Of course, the whole slew of initial tests — CXR, EKG and troponins — are negative. But since this is the age of ambulance-chasing lawyers and uncontrollable malpractice premiums — the patients are admitted for a 24hr observation and an unnecessary and expensive stress test which the hospital probably won’t get paid for given the often “self-pay” status of these patients.
Trying to outdo these manipulative patients, we refuse to give them their narcotic pain meds and limit them to NTG and tylenol. But our attempts at negative reinforcement is often defeated by our hospital’s ER who puts just about anyone with a pain complaint on dilaudid.
Want more examples, Matt?
“Matt, why shouldn’t physicians blame their patients?”
Your patients aren’t the reason you have only 5 minutes to see them. Your patients aren’t the reason their insurance company underpays you. You, and the contracts you sign, are.
The fact that you even ask the question illustrates just how far even basic concepts of client service have been lost to the profession. When I hear physicians speak longingly about the “free market” and how great it would be I chuckle because it seems from your comments that few of you have the interpersonal skills that would keep people who had a choice coming back.
Does it stink that some don’t speak English? Sure. But were those people actually paying your salary, your overhead, etc., rather than the govt. or your insurer you wouldn’t see a headache, but a marketing opportunity. Like banks and accountants do with Spanish speakers. Yet you can’t conceive of such a thing because the actual thought of treating these people as customers has never occurred to you.
That’s not entirely your fault, you don’t know any better because for 40 years that’s how most doctors have been paid. You are simply reaping what your profession has sown.
You blame lawyers for the fact you do all that to drug seeking addicts? Are you serious? What lawyer wants a client who presents that poorly to a jury, has no lost wages, and a host of other problems any resulting damages can be blamed on? Again, take responsibility for your actions, for your choices. Until you do, nothing will change.
Just a few observations from my point as a mother and a nurse.
When my children were young and even into their late teens, I think they made ER visits twice. Once for a broken ankle, the other for a pretty bad cut on her wrist that required stitches. My children went to the doctor’s office for routine immunizations and childhood illnesses. Yep, they went to the doctor before I even thought of an ER visit. Imagine that?
I didn’t bring my children into the ER for a cough, congestion, fever that was controlled by tylenol, constipation, or because they just wouldn’t stop crying. As a nurse, I have seen countless times when parents bring their children into the ER (and I mean ALL the children they possess) and demand to be treated immediately for those same complaints.
Also, never in my wildest dreams would I have thought to tell the ER doctor that my child just “quit breathing” so that I could have a weekend babysitter while I went away. Trust me, it happens often. The child arrives on Friday afternoon, the “not breathing” story is told, the admission is inevitable, and the parents leave for the weekend.
What is left for the ER doctor to do? He is left to practice “defensive medicine.” How can he not? And as for the residents lack of sleep, it will only be a matter of time (and I think it has already happened) that the resident will be sued for malpractice because he was exhausted and missed or ordered something incorrectly.
Times have changed. We don’t put up houses using only a saw and hammer, we used power tools. We don’t break men’s backs to put up steal girders, we use cranes. What’s wrong with bringing medicine into the 21st century. I’m not saying not to teach doctors how to arrive at a working diagnosis in their heads, but why not give them the power tools to use to get the definative diagnosis quicker?
Of course, I could be just way off course, you never know.
“Like banks and accountants do with Spanish speakers. Yet you can’t conceive of such a thing because the actual thought of treating these people as customers has never occurred to you.”
First of all, I never said I would not treat the Spanish Speaking patients. It’s my ethical obligation to treat any patient regardless of his/her demographic profile. I am going to Diagnostic Radiology after this year at which point I couldn’t care less what language the hospital patients spoke.I was just being ciritical of their refusal and indifference to learn English. Just because Corporate America, through providing Spanish-speaking customer rep, makes it easy for them not bother to learn Englsh, doesn’t mean the society including physicians shouldn’t expect them to learn the language of this country. I, for one, am seek of having to press ONE for English everytime I call a service company.
“You blame lawyers for the fact you do all that to drug seeking addicts?”
Well yes, atleast partly. Why do you think we have to repeatedly admit these addicts for 24-hr observation despite close-to-none suspicion for a MI based on the initial tests even when we know they are just making up symptoms to get their pain medication? Imagine for once, we threw their behinds out of the ER and one of them drops dead of MI one year (possibly for cocaine-induced MI. Every lawyer in town will have a field day in with our claims of “very low clinical suspicion for MI” and “patient’s lying shepherd behavior.”
matt,
how exactly are we physicians to ‘take some responsibility for our situation?’ how, exactly, is it my fault that physicians 40 years ago made a ‘faustian bargain’ with the government?
as panda has pointed out here and as you will read all over the medblogosphere EMTALA is what makes American medicine a ponzi scheme/money-grab and not a business.
EMTALA is an unfunded mandate and all physicians, because of it, are forced, by the government, to give away their services to anyone, citizen or not, who has an ’emergency condition’ which, of course, is not defined.
yes, because of the fear of litigation, people with sniffles and a headache all get spinal taps, people with chest pain get admitted, people with a story consitent with TIA get admitted, CTs are ordered every few seconds, and even if the emphysematous old man who still smokes 3 packs a day and is on home oxygen at your expense, matt, is feeling better after his nebs and steroids and antibiotics his pulse ox of 84 will get him admitted for the 8th time this year to the same exhausted hospitalist.
yes, the illegal immigrant who gets thrown out of the back of a pickup in rural bumfuckia will get a helicopter ride to the trauma center and the best care in the world when he would have died if he had done the same thing in his home country and you will pay for that too.
why, exactly, matt, would we want to ‘improve customer service’ to get these fine folks to visit us more frequently? why, exactly, does it matter a single bit whether the guy dying from a heart attack likes me as i save his life? because when he has his next one at another hospital he might like the next doc better and decide to have his third one there?
today i worked 11 hours on my ‘ten hour’ shift. 3 of those hours were spent filling out paperwork and trying desperately not to choke three different drug-seeking psyche patients while trying to get someone at another facility to accept critically ill patients in transfer.
customer service? i’m a doctor. patients will always be patients to me. we are not on equal footing. they didn’t come to me to buy a car. if they don’t like me fine. i’m a nice guy but i’ve had it with people with no means acting like they are john rockefeller. if customer service gets any more emphasis in medicine watch a lot of us walk. in 9 months i am, if the stars align, leaving emergency medicine. it will be because of people like you, matt, and patient’s who believe that they are customers.
“EMTALA is an unfunded mandate and all physicians, because of it, are forced, by the government, to give away their services to anyone, citizen or not, who has an ‘emergency condition’ which, of course, is not defined. ”
No you’re not. You are only subject to it if you choose to practice a particular type of medicine and need hospital priviliges. That’s your choice. Many physicians choose to go another route.
“yes, because of the fear of litigation, people with sniffles and a headache all get spinal taps,”
Is it the patient’s fault that you take action based on a risk you do not understand or have any real knowledge of? No. If you refuse to use your best professional judgment, that is YOUR choice. No one else’s, so stop blaming everyone else.
” i’m a doctor. patients will always be patients to me. we are not on equal footing. they didn’t come to me to buy a car. if they don’t like me fine. i’m a nice guy but i’ve had it with people with no means acting like they are john rockefeller. if customer service gets any more emphasis in medicine watch a lot of us walk.”
Where are you going to go? The rest of the world operates on that premise. That’s what occurs in the free market. You treat the people paying you well because you want them to keep doing it.
(Whoa. Overdosing crack addicts and drug seekers are not paying us. Isn’t that obvious? EMTALA means they get free care at your expense. By the way, the world does not operate on that premise at all. The Europeans, for example, especially the French, are having almost the exact same problems with their Emergency Medicial services as we are…but worse because there is much less of an incentive for a French doctor or a nurse to put in the long hours that are common for Americans.-PB)
You have the luxury of blowing us off because you aren’t directly answerable to us financially. And since you won’t answer to us, we’re going to make you government employees, and then you truly will all be subject to EMTALA and every other whim of the government. Most of us have no problem with our tax dollars providing basic emergency care to everyone. The question is what do we provide from there.
I’m sorry you had to work hard. But guess what – you’re not the only one. And it’s a choice you made. If you don’t like the patients you are dealing with, find another specialty to enter.
“So I can take my leisurely time figuring it out but as I am going to get the CT anyways it is not an efficient use of a physician’s time. ”
That’s why I said “instead†of doing an exam (I even highlighted the term with little stars to draw attention for the casual reader).
My point is I get pateints all the time where someone has ordered CT or MRI inappropriately because they didn’t do a neuro exam to see if imaging is indicated and if so, what type of imaging and what region. Common examples are cervical MR in patients with diffuse neuromuscular disease, neck CT in patients with a brain lesions, and so on.
A penlight and little rubber hammer are considerably cheaper than a million dollar magnet. More importantly though, the patient interaction involved in doing an exam has tremendous benefits for the patient and doctor beyond the financial aspects.
Thanks for letting me go off on this; it’s sort of a pet peeve.
I fell better now.
Matt (CJD)
We know the risks of testing. I can tell you what they are. You can decide whether you want it or not. Take it or leave it. If your IQ is less than say 100 then I will decide if you should have it, since I don’t need you feeling up my leg.
Sure we could all enter the free market and do botox, spider veins, etc… However EMTALA, ER call panel specialty problems are not just are problems. It is your problem if you unfortunately wind up needing emergency care. What? The ER is full? There are no hsopital beds? There is no neurosurgeon, hand surgeon, plastic surgeon, neurologist, orthopedist, ENT on call to help me? Guess I better try to sue the ER doc.
“You have the luxury of blowing us off because you aren’t directly answerable to us financially. And since you won’t answer to us, we’re going to make you government employees, and then you truly will all be subject to EMTALA and every other whim of the government. Most of us have no problem with our tax dollars providing basic emergency care to everyone. The question is what do we provide from there.”
Hahahahah. Just wait ’til your hospital is like a DMV. You’ll have gotten your wish.
“No you’re not. You are only subject to it if you choose to practice a particular type of medicine and need hospital priviliges. That’s your choice. Many physicians choose to go another route.”
This is patently false. Hospitals have government enforced monopolies that prevent competition without prior approval. Those same hospitals then often require specialists to do ER consults as a condition of hospital priveledges. The specialist has a limited number of options due to government mandate. While some specialists have now found other ways (ie: independed surgery centers, admitting to hospitalists, etc…), these things are often hit hard with red tape. The government is constantly looking for ways to force physicians to cover the ERs, and anyone covering the ER is subject to EMTALA. The reason no one wants to take call is that it is unprofitable. You have less chance of getting paid and more chance of being sued. If the patient paid and malpractice were reasonable for emergencies, there would be no crisis in the ER.
It is not a choice, unless you are talking about the the broader choice of practicing medicine at all. I don’t think that we should take the attitude of take it or leave it with all physicians, because too many deciding to leave it is probably a bad thing.
Why do you guys think you have more chance of being sued from people who can’t afford their medical bills? That just illustrates you continued lack of understanding of basic economics.
(Are you for real? Dude, malpractice attorneys advertise for clients on TV-especially late night TV when my typical welfare patient might be expected to be watching-and they are quick to point out that they will work on a contingency basis. The basic economics are that everybody will take the jackpot or the windfall if they think they can wrangle it. Also, as has been pointed out, serving an indigent, largely non-medically compliant patient population who indulge in many high risk behaviors maginifies the risks of practicing medicine. The “Standard of Care, however, upon which medical malpractice lawsuits are litigated, rarely takes into account patient behavior. A lawyer who thinks he has a case will work for rich client as soon as he well for poor client because either way he is working on contingency and it just isn’t going to matter who the patient is, just what he he alleges was done to harm him.
Maybe I give you too much credit. To pose a ridiculous hypothesis, the gist of it being that the poor patients can’t sue doctors because they are poor is mind-boggling in it’s lack of understanding as to how the system works. -PB)
And until you do take the “take it or leave it” attitude, nothing is going to change. The only people who can change things like how you’re paid, EMTALA requirements, etc., are you guys. You have to stop signing bad contracts. You have to tell the hospitals no. You have to tell the federal govt. no. Will it effect your income in the short term – undoubtedly.
“It is your problem if you unfortunately wind up needing emergency care. What? The ER is full? There are no hsopital beds? There is no neurosurgeon, hand surgeon, plastic surgeon, neurologist, orthopedist, ENT on call to help me? Guess I better try to sue the ER doc. ”
If I live in a rural area, I probably don’t have those specialties available anyway, do I? If you’re arguing they should always be available along w/ plenty of beds, aren’t you agreeing with the “healthcare is a right” people? And if healthcare is a right, then the govt. is far more likely to be running it.
Until you guys break free from this mentality that your patients are just problems and the only payment model is the existing one, then nothing is going to change. And hey, maybe you’re just bitching to bitch, because the truth is this payment model comes as close to guaranteeing a pretty good standard of living as anything in the free market.
“Why do you guys think you have more chance of being sued from people who can’t afford their medical bills? That just illustrates you continued lack of understanding of basic economics.”
EMTALA refers to emergency medical care, which is inherently more risky for the patient, more difficult for the practicioner, and therefore more likely to have a bad outcome. Today’s legal environment promotes the idea that malpractice is a patient safety net in the event of any bad outcome, and not for incompetence (two different things). Thus, caring for EMTALA patients is a financial and legal risk.
Many practicioners decide to “leave it on the table” like you say, but the result is areas of the country that become critically short of services. OB comes to mind. You also get hospitals that cannot cover all services (since docs have opted out) and patients get sub-par care. You don’t have to be in favor of socialized healthcare to be against a system that promotes the production of a poor product.
To get a free market, then we need to eliminate the current system, go back to fee-for-service, and give docs the ability to deny care if one does not have the funds.
“in 9 months i am, if the stars align, leaving emergency medicine”
911doc, are you going to do another residency?
Matt CJD
“If I live in a rural area, I probably don’t have those specialties available anyway, do I? If you’re arguing they should always be available along w/ plenty of beds, aren’t you agreeing with the “healthcare is a right†people? And if healthcare is a right, then the govt. is far more likely to be running it.”
1. Maybe not, but 10-15 years ago you were much more likely to. And it was certainly easier to find a place to transfer you to if you did need it.
2. No. I personally don’t believe healthcare is a right but the availability of good emergency and specialty care is a good thing, don’t you think? Do you want me to debit 500$ dollars from your mastercard before I treat you for your life threatening heart attack?
“And until you do take the “take it or leave it†attitude, nothing is going to change. The only people who can change things like how you’re paid, EMTALA requirements, etc., are you guys. You have to stop signing bad contracts. You have to tell the hospitals no. You have to tell the federal govt. no. Will it effect your income in the short term – undoubtedly.”
You would really have fun with that one wouldn’t you CJD if all ER docs and specialists who take call for the ER went on national strike and shut down ER’s ??? You would give the line about all these 150K+ earners “whining” and not disregarding professional ethics and the hipocratic oath and all of that B.S. It would be a trial lawyers wet dream to go after those who abandoned “their duty”.
You are a seemingly intelligent guy who truly seems interested in the health care issue and likes to engage in debate. Your persistance at debate is surpassed only by your attachment to your own preconceptions of medical practice and narro viewpoint
P.S.
Personal anectdote. Roughly 50% of the people I see in practice are insured, 25%medicaid/medicare, 25% no pay. 90%+ are U.S citizens. I don’t know any of this info about any particular patient until after I have treated them.
I have been sued 7 times in 16 years. The breakdown:
-2 times from illegal alien no-pays
-4 times from medicaid patient
-once from an insured patient
maybe the demographic is aberrancy, but I don’t think so. These are the Indian gaming and Powerball players.
” Today’s legal environment promotes the idea that malpractice is a patient safety net in the event of any bad outcome, and not for incompetence (two different things).”
This is patently false, given the fact that the number of med mal claims pales in comparison to the number of “bad outcomes”, however defined.
“Many practicioners decide to “leave it on the table†like you say, but the result is areas of the country that become critically short of services.”
And. . . . ? Is every area of the country entitled to healthcare services?
“Dude, malpractice attorneys advertise for clients on TV-especially late night TV when my typical welfare patient might be expected to be watching-and they are quick to point out that they will work on a contingency basis. The basic economics are that everybody will take the jackpot or the windfall if they think they can wrangle it.”
Of course, to get said “jackpot”, you have to have a pretty significant injury. Tell me, how many people who have had $1 million plus awards for med mal would you trade places with? Would you trade their injuries for the money? Of course, don’t forget, much of the money goes right back to healthcare providers. Are you kidding with that “jackpot” stuff? I’ve never met a med mal plaintiff with a verdict or settlement who wouldn’t rather have had the doctor perform up to the standard of care in the first place. Have you?
(Again, whoa. Patients can and often do have bad outcomes even if the standard of care was outstanding and they will sue because of it. All the lawyer has to do is find an error in the paperwork and upon this he may build a case or at least the possibility of a settlement. And the “small fry,” the late-night lawyers, are not trolling for the twenty-million dollar case but the smaller, bite-sized awards that they hope can be settled out of court. Even the multi-million dollar awards are not always won on the basis rationality.
On another note, it is impossible to practice perfect medicine, especially in the Emergency Department with, as has been pointed out, a deluge of mostly unknown, often medically non-compliant, and usually very sick patients. The standard of care is the same for an orthopaedic surgeon, for example, whether he sees a well-known patient in the office and schedules her for a routine knee replacement or whether he sees a drunk crack whore in the ED after an MVA. That’s why it’s getting harder to get specialists to come in. Because, as was pointed out, Good Samaritan laws don’t apply and even though the specialist is working for free on a potential time-bomb of a patient, one who once he lays hands on is his for the duration of the treatment which can be months of years, he is held to the same legal standard. If you don’t think this is a problem and specialists refuse ED call just because they are greedy you are living on a different planet. Most physicians like to do good, like to exercise the noblest side of the medical profession, but won’t do it if they are asked to routinely risk their reputation, their credentialing, and their livelihood.-PB)
“The “Standard of Care, however, upon which medical malpractice lawsuits are litigated, rarely takes into account patient behavior. A lawyer who thinks he has a case will work for rich client as soon as he well for poor client because either way he is working on contingency and it just isn’t going to matter who the patient is, just what he he alleges was done to harm him.”
As usual for a physician, you miss the basic economics. Without a significant injury or significant lost wages, the economics of taking the case to trial for the plaintiff’s counsel, who is not getting paid by the hour as defense is, plus the inherent risks involved in any trial, make it difficult to take on. Most med mal lawyers reject 10 cases for every one they take.
” To pose a ridiculous hypothesis, the gist of it being that the poor patients can’t sue doctors because they are poor is mind-boggling in it’s lack of understanding as to how the system works. -PB)”
You misunderstood, which may be my fault for not being more specific. I assumed you understood the economics of law practice, which you clearly don’t. Obviously poor people can sue, but they better have some significant injury or otherwise it’s simply not worth it to the plaintiff.
Back to the point – here’s a question. Why do any of you think that your practice conditions will change if you keep signing contracts that pay you in a way that does not reward you for the time you spend with the patient?
And if you’re going to threaten that people will lose services if the public doesn’t give you this or that (liability protection, more money, etc.) aren’t you impliedly agreeing that everyone does have a right to healthcare? And to a specialist within X miles of their home?
“This is patently false, given the fact that the number of med mal claims pales in comparison to the number of “bad outcomesâ€, however defined.”
You defined “bad outcomes” in the following:
“Obviously poor people can sue, but they better have some significant injury or otherwise it’s simply not worth it to the plaintiff.”
So significant injury = bad outcome = med mal? What is missing in that reasoning is that a physician can follow the standard of care and the patient still have a significant injury. There is risk associated with every procedure that the best physician cannot eliminate. A doctor can not magically remove a patient from the effects of chance (or their lifetime of choices) and put them in a haven of zero-risk.
“And if you’re going to threaten that people will lose services if the public doesn’t give you this or that (liability protection, more money, etc.) aren’t you impliedly agreeing that everyone does have a right to healthcare? And to a specialist within X miles of their home?”
An economic decision (whether to practice in state x or not) is not a threat. How is this any different than an athlete negotiating for a bigger contract?
QUOTE
And if you’re going to threaten that people will lose services if the public doesn’t give you this or that (liability protection, more money, etc.) aren’t you impliedly agreeing that everyone does have a right to healthcare? And to a specialist within X miles of their home?
UNQUOTE
No, of course not. All that is being impliedly agreed on is that everyone NEEDS healthcare.
Just as everyone NEEDS access to food, yet nobody gets this ridiculous notion that this gives them a RIGHT to food.
Saying that someone has a RIGHT to something means that 1) he/she has a natural RIGHT to it, like freedom etc 2)somebody else has an obligation to provide sth to him/her (right=claim). Neither is the case with healthcare.
“So significant injury = bad outcome = med mal? What is missing in that reasoning is that a physician can follow the standard of care and the patient still have a significant injury.”
No, that’s not how I defined bad outcome. A bad outcome can be an insignificant injury. All I was noting in the phrase you cited is that the economics require that a person with little in the form of lost wages is going to have to have a significant injury before the attorney is going to spend the money to hire an expert to even see if the standard of care is met.
“And until you do take the “take it or leave it†attitude, nothing is going to change…Until you guys break free from this mentality that your patients are just problems and the only payment model is the existing one, then nothing is going to change.”
Something tells me Matt is trolling. The random insults to MD’s intelligence are telling.
However, he raises one good point, which is why I’m going to feed the troll (just this once). MD’s do passively agree to poor treatment in order to treat patients.
Most doctors become doctors in order to help people with their illnesses. In truth, the high pay is simply a perk to convince those talented enough and with this certain inner drive to choose -this- career (coming with a huge schooling/debt/personal investment) as opposed to, example, becoming an economist. I believe this is what Matt doesn’t, and will never, understand.
Doctors are not economists. They are not lawyers. They deal with things of a different importance level. Life and death. It’s not being overly dramatic, it’s truth.
So when someone, like Matt, insinuates that doctors everywhere need to RISE UP and DEMAND better pay OR ELSE WE WON’T TAKE YOUR CRAP PAY (TREAT PATIENTS), well, it’s pretty much a foregone conclusion that doctors will see right through that as being ethically untenable. Maybe not for those who are concerned primarily with economics, but for the kind of person who becomes a doctor.
It’s an unusual position that doctors are in. Utterly humanitarian but (in our country) utterly capitalistic. Don’t try to take your generalizations based on the purely-capitalistic professions and project them on the profession of physician. You just don’t understand it well enough to do so.
I think most physicians would agree with me, even those who are more savvy with the economics than I am.
“Doctors are not economists. They are not lawyers. They deal with things of a different importance level. Life and death. It’s not being overly dramatic, it’s truth.”
Actually, it is overly dramatic. Not all physicians are saving lives every day. My podiatrist isn’t dealing with “life and death”. Nor is the plastic surgeon, the orthopedic surgeon, etc.
(I think I save at least one life per shift.-PB)Â
“So when someone, like Matt, insinuates that doctors everywhere need to RISE UP and DEMAND better pay OR ELSE WE WON’T TAKE YOUR CRAP PAY (TREAT PATIENTS), well, it’s pretty much a foregone conclusion that doctors will see right through that as being ethically untenable.”
This would mean more if you guys didn’t threaten to leave places every time you didn’t get immunity from your mistakes, or didn’t threaten to drop out of the profession if CMS continued to cut your pay. You may view yourself this way, and that’s great, but it doesn’t go across the board.
“It’s an unusual position that doctors are in. Utterly humanitarian but (in our country) utterly capitalistic. Don’t try to take your generalizations based on the purely-capitalistic professions and project them on the profession of physician”
Seriously, are you saying this with a straight face? I’ve represented physician groups when they split up and seen just how much the money matters. Over 900,000 physicians sued health insurers because they believed they were wrongly denied payment.
Please, spare us the holier than thou angle. You guys spend too much time trying to put more money in your pockets for that to be the case.
Doctors are like god in that everyone complains about them, but when your life is on the line you run to the nearest doctor begging for help. Matt be happy that one day the very people whose intelligence you question and insult will be making decisions about your most precious commodity your health. Scary eh?
As for lawyers I liken them to the devil, you only strike a deal with the evil one if your life is already gone to hell.
Yep, he is a just troll. His basic never ending circle jerk on multiple blogs, and clearly highlighted above, is:
Matt: Stand up for yourselves. Don’t sign bad contracts with insurers/government. It is business you know
Bloggers: OK, we are/will. But this is what/will happen.
Matt: Aha, You are just a bunch of greedy holier than though bastards.
Let’s see if I can address your attacks in an orderly fashion:
1. Lawyers are evil. OK, if you say so. Of course, when you get yourself in a jam, who do you call? When the health insurers start screwing you on reimbursements, who do you call? When your partners in your practice start screwing you, who do you call? When your kid gets run over by a drunk driver and you can’t afford a lifetime of bills and the lost income in caring for them, who do you call?
2. That physicians are greedy. I’ve not claimed this once. You’re motivated by financial self interst like everyone else. It gets tiresome listening to your sanctimonious bs when what you’re really doing is trying to put more money in your pockets, and if you think me pointing that out is saying you’re greedy, that’s fine. But really, I don’t care if you are greedy. I think you should receive the maximum value your services are worth in the market. If you’re good, I don’t mind paying for your services.
I want you to think about it because as a consumer of healthcare, I don’t want the govt. to control the whole industry. But it’s frustrating when the people with the most skin in the game, physicians, do nothing whatsoever to move us to a free market. Sure, they bitch incessantly about how bad single payer will be, yet you offer no alternatives. You just continue down the same path you’re on now, where the govt. dictates your practice. Sure you cry and moan, but you never DO anything.
We, the public, even if we agree with you, have no options to turn to in order to improve things. The only thing you offer us politically is protection for your liability carriers. It seems the only time you guys propose legislation is when your liability carrier drafts it.
You can insult everyone you want, but the fact remains that the single payer train is coming down the track, and physicians have the best chance, and the most interest, in changing it. Because while it might affect me only when I’m sick, it will affect you every working day of your life. Perhaps you should use some of the political vigor you showed in working for your liability carrier on yourselves.
Hi everyone, I did four years of post-graduate professional training, too, but the general public views the value of my existence as somewhere south of a rabid pit bull so I’m doing my damnedest to prove them right.
Doctors aren’t a giant monolithic entity who can stop the runaway freight train that is the federal government with force of will. They don’t take call and spoil to go into dermatology because at the end of the day that’s choice that’s (sorta) left to them as individuals. Overturning EMTALA, yeah, not so much. Same predicament a citizen dissatisfied with the government has, with the exception that they didn’t just suffer through 11+ years of school and training and are several hundred thousand in debt. As is the general reason why most government mission creep continues unopposed, most of us already have enough on our plate without devoting ourselves to tilting at windmills. Maybe you see them fighting liability partly because it’s something most can agree on and is a generally winnable fight in the court of public opinion. It’s a lot easier for the opposition to cue the violins, regardless of the underlying merits, when the target is emergency room patients (which nearly everyone can easily identify with) than when it’s lawyers (which nearly everyone will gladly pile on to at first opportunity). You’ve said you know all about picking your battles, right?
“Seriously, are you saying this with a straight face? I’ve represented physician groups when they split up and seen just how much the money matters. Over 900,000 physicians sued health insurers because they believed they were wrongly denied payment.”
Uh, yes. I am saying it with a straight face. Which further proves my point, that you are clearly out of your element.
Those physicians didn’t refuse to treat patients, did they? Maybe some did, but I’m sure they didn’t do it lightly. Fighting to get paid for services rendered and going on strike are two completely different ways of dealing with a problem. When you are providing life-and-death services, one is ethical, the other is not.
Though this will not make a difference to your argument, as anyone who has taken ‘internet trolling 101’ knows. Your next turn will be to say “You’re obviously an incompetent nincompoop who’s too sentimental to also be making money and I pity you.”
Then I say, “I need to go do something so incredibly awesome in my real life that I can’t be bothered to respond to you any more. Like, skydive, or go to my mixed martial arts class, or have sex with a hot woman. Maybe all three.”
Then you say, “Ha! He ran away, so clearly I won the argument!”
“Maybe some did, but I’m sure they didn’t do it lightly.”
Wait, I didn’t know you had the power to read minds. No wonder you’re so smart.
” Fighting to get paid for services rendered and going on strike are two completely different ways of dealing with a problem.”
Who said you should go on strike? You’re really beating up these strawmen, I’ll give you that. But that’s not what I said. I simply think you should stop signing the contracts that you then turn around and whine about. Doesn’t mean you can’t still see patients if the govt. doesn’t pay you. Somehow, someway, that’s how physicians did it for decades.
I don’t think you’re too sentimental at all. You’re just as interested in money as everyone else, it’s just that everyone else doesn’t cloak it in as much blather about how they’re saving humanity. Hell, every time you screw up and someone asks you to pay for it we get lectured on how there are so many variables and you can’t control everything. You want it both ways.
All I’m saying is that you have got to quit expecting things to change when you keep doing the same thing over and over. Why would anyone pay you differently if you keep signing the same agreement? And if you’re going to keep signing it, for goodness sake, sack up and take responsibility for the results. Stop whining all the time.
For the “turd stuck up there”, I think rather than a digital exam, a Head CT would’ve probably found it.
OK, back to your arguing.
Hi Panda Bear, what is your take on “universal medicine”? If Mrs. Clinton wins, I mean if, she might try to push the universal medicine plan (so will all other Democratic candidates), which might dramatically decrease the income of physicians.
if you are so fed up with the way emergency rooms operate and that many patients use the ER inappropriately, then why the hell are you an emergency physician. you probably should stop griping and start getting involved in the politics of your hospital so you can train your triage nurses more effectively.
response to mike above, on the subject of spanish speakers who dont want to speak english. i am talking about health personnel who put down spanish speakers. i think thats a lousy excuse for an emergency room doctor or anyone working there. if the patient does not speak english, then you should have a translator, which probably protects you more than it does the patient. if you dont like the fact that some people, who are us citizens, prefer to speak spanish in a free country, maybe you should move to another country where they are racist against everyone else.
I have been a nurse for thirty years and I can not take it one more time if someone says at work Press Ganey reports. I’m amazed at what admin will listen to.My favorite is “where’s all the prutty nurses”or my nurse didn’t smile, my rooms dirty,food was bad and on and on. Everyone knows the first thing admin cuts on the budget is houskeeping food services and increase the nurse pt. ratio. How about asking the doctors and nurses how to make things better and get the standard “we can’t afford more staff.” Maybe its time a nurse or a doctor sue a pt. for the emoitional abuse never mind the physical abuse.