Stealth Medicine and Other Topics

An Apology

I want to apologize to the distinguished elderly gentleman sitting on the hall bed. It was a little insensitive of me to stand at the coffee machine taking my time making a cup of coffee not five feet away from you and your wife while you waited to be seen by a doctor. When I walked around the corner to check the board, although you didn’t know it, I was still only five feet away and I heard every word of your verbal broadside delivered against lazy doctors making people wait in busy hallways while they took in-your-face coffee breaks. After I heard this I quietly asked the charge nurse how long you had been waiting and I was doubly ashamed. I don’t like to see people waiting in the department and I blush to think that on many occasions this is the result of my inefficiency as a resident.

In my defense however, my shift had ended almost an hour before I had that cup of coffee and I was just hanging around waiting for some lab results so I could get a disposition on a patient. I wouldn’t say I was “off the clock” because we don’t have a clock per se but I was certainly not picking up new charts. Even towards the end of a shift residents get kind of antsy about picking up a new patient because, while we sign out patients who will obviously be in the department for a long time, it is common to stay quite a while after the end of a shift tying up loose ends. We never know for sure if a new patient will turn out to be an easy disposition or a disaster who keeps you in the the department three hours past the end of the shift.

One day, towards the end of my shift and after some surrepetitious cherry-picking I selected a low-priority chart with a chief complaint of “headache” which I thought might be a chronic migraine patient and therefore an easy disposition. The patient turned out to have meningitis and required a lumbar puncture, central lines, intravenous antibiotics, intubation, a critical care admission and the kitchen sink. This is not the kind of patient who you sign out. Don’t get me wrong, it was a great patient and I don’t mind staying late for something as important as that but I do like to get home too. The point is that you definitely do not want to pick up an abdominal pain patient with only a half hour left. To much potential for badness.

But I digress. The real point is that long waits are the future of medicine. Not only are there not enough doctors to go around, especially in primary care, but we have an aging and incredibly sick population already making huge demands on our very finite medical capacity. Compounding the problem are diminishing reimbursements to physicians, madcap and increasingly byzantine bureacracy, a predatory legal environment, and the resulting complete lack of common sense that makes it increasingly impossible for physicians to adequately treat the patients they see now let alone the marauding horde of aging baby boomers about to despoil such capacity as we currently maintain. I don’t see how it is going to get any better and more importantly, I don’t see why you put up with it.

You see, I looked at your chart and your complaint, while not trivial, was not something that couldn’t have been addressed by your own doctor if he were so inclined which he wasn’t. Obviously when he factors all of the variables into whatever mental black box he uses to decide whether to fit you into his schedule, sending you to the Emergency Department was the easier choice. I know perfectly well that he is already swamped with patients, many of them horrifically complex, and I don’t envy him as he tries to fit them into his hectic clinic. There must come a point where the relatively small reimbursement he receives for the one extra patient is not worth the time it takes from his family. And that’s the problem in a nutshell with primary care, namely that the reimbursement for the time it takes to sort you out and customize a medical regimen is not enough to make it either economically or professionally appealing. If your doctor only gets a pittance to see you, he needs to see a lot of patients to make a living leaving less time for each one. He’s not a bad guy but he has the same finacial pressures on him as you once had before you retired and if you knew how little Medicare reimbursed him for his time, you could easily do the math and see that he’s not exactly as filthy rich as you imagine him to be.

So I ask again why you put up with it and the answer is simple. Because you have never considered paying a doctor with anything other than insurance and even your co-pay is given reluctantly. On one hand this is understandable. As a retiree you have paid into the Medicare system for your entire life, not to mention paying either directly or indirectly into a private health insurance scheme since you first started working. On the other hand it is also understandable that your doctor isn’t exactly jumping for joy at his reimbursement from either the government or your insurance company, two entities whose sole purpose seems to be playing a game of chicken with doctors, that is, seeing how little they can actually pay them before they throw up their hands and look for another way to make money. So far it’s the doctors who have swerved off the road but eventually this is going to change. I have talked to many primary care physicians who are getting seriously fed up with the way things are going. Like you, they are locked into the insurance mindset but it will only be a matter of time before medical doctors realize that many American retirees are not poor, need fairly detailed primary care, and might be willing to pay for it if they preceived good value for the money. By this I mean the ability to have timely access to their physician with appointments that are long enough to address their many medical problems. When physicians and patients realize that each can provide value to the other, a good service for fair compensation, both of you will finally break free from the insurance prison that has been built around you.

This sort of practice is called “boutique” or “concierge” medicine by its detractors, especially by those who demonstrate their compassion by giving away other people’s time and money as if it were theirs, and they act as if it some completely alien economic model thought up by a zany college professor when it is instead the economic model that governs almost every other transaction between buyers and sellers.

As a patient, you’re locked into medicare and it may gall you to have to pay for a service that you expect to be free. But there you are sitting in the hallway of an urban Emergency Department rubbing elbows with the usual drunks because your primary care doctor did not have time to see you. If access is worth it you’ll pay, if not stand by for longer waits.

Stealth Medicine

To be a chiropractor in America is to lead a double life, trying to fit in with the world of real medicine while at the same time practicing a form of medical therapy based on a thoroughly discredited treatment modality. Officially, chiropractors have backed away from some of their more outrageous claims instead deciding to settle on the huge chronic musculoskeletal pain market of which chronic low back pain alone would seem to provide the potential for rich provender from now until such a time as the sea shall give up her dead. We’ve reformed, they proclaim. All of that hokey subluxation stuff? That’s so ninteenth century. No more relevant than the real medical profession’s use of bleeding back in the Bad Old Days before we got all scientific. Indeed, you’d be hard pressed to find a chiropractor claiming to be anything other than a hard-workin’, back crackin’, pain relievin’, dutiful member of the health care team doing his bit and making sure to refer to appropriate specialist when he gets in over his head.

Nobody here but us super-powered physical therapists. Move along. Nothing to see.

And yet it cannot have escaped your attention that the latest frontier of chiropractors is pediatrics where they hope to make inroads into a population that is not exactly suffering from a lot of chronic musculoskeletal pain. That most kids are fairly healthy is an axiom of pediatrics and the diseases that they acquire are usually fairly benign and self-limiting. They certainly do not have the kind of vague low back pain that is the bane of the Emergency Physician but the delight of the chiropractor. What, then, are the chiropractors proposing to treat in your children? Certainly not real pediatric diseases as the International Chiropractic Pediatric Association is quick to point out. Whatsamatta’? Don’t you read? “The doctor of chiropractic does not treat conditions or diseases.” Says so right in their mission statement. But then a little further down it ascribes complaints in every system to our old friend the subluxation and promises, by judicious adjustment of the pediatric spine, to allow the body to express a better state of health and well-being.

Apparently chiropracty can resolve asthma, ear infections, colic, allergies, and headaches to name just a few. What then, exactly, are pediatric chiropractors doing if it’s not treating conditions or diseases…or is your poor Uncle Panda, lumbering asian bear-mammal as he is, just lost in the semantics? In their mealy-mouthed way, chiropractors are trying to make an end-run around the ridiculousness of their profession to become your child’s pediatrician, a job for which they are singularly unqualified for many reasons the most important of which is that they have no training in pediatrics (the real kind, I mean).

Look at it this way. For the sake of the argument lets say that all chiropractors decide that subluxation theory is idiotic and henceforth devote their lives to evidence-based physical therapy. That’s kind of the angle the so-called “reform” chiropractors take in opposition to their “straight” brethren who ascribe almost every pathology including infectious diseases to subluxations. Would you take your child to a Physical Therapist for routine health maintenance, well child checks, or even something as serious as asthma? Of course not. And no Physical Therapist would touch your child in this capacity for the same reason I don’t perform abdominal surgery, namely that it is well outside of my training and my legitimate scope of practice.

Pediatrics is not surgery. The risks are generally low which is why chiropracters believe they can move into it safely. It’s hard to screw up on a kid after all, even as a legitimate pediatrician but especially as a pretend one. Adjust a few spines, twist a few bones, and marvel that most of your patients never seem to get any diseases despite not being vaccinated. But you’re playing with fire. Eventually you are going to get the childhood leukemia or the cystic fibrosis patient and you, in the full flower of your ignorance, are going to keep adjusting the spine oblivious to the depth of your folly.

29 thoughts on “Stealth Medicine and Other Topics

  1. This is a major reason I left chiropractic school after one semester. I realized that I would never be comfortable with my level of ignorance about disease. So now, after trying out another career for a while, I’m in med school.

    BTW, I’d still go to a chiropractor for certain problems (i.e., uncomplicated lower back pain). In fact, I might even refer a patient to one, assuming I were very familiar with the chiropractor’s treatment philosophy and practice. To dismiss spinal manipulation as a “thoroughly discredited treatment modality” is a bit of an exaggeration. There haven’t been enough studies to thoroughly discredit (or validate) it, but studies so far tend to show that it doesn’t hurt (except in extremely rare cases of vertebral artery dissection in cervical manipulation) and it may be more effective than other treatments, at least for lower back pain.

  2. Dude, word.

    The unfortunate thing about this game of chicken the government plays with physicians and their reimbursements is that it hurts the neediest of people–those who can’t afford insurance, much less the outright cost of a doctor visit. My grandparents had enough income in retirement to pay for their own insurance, yet felt entitled to free care and wondered why they couldn’t get free drugs, where a friend of mine who is on Medicare due to a disabling disease can’t get a physician to take care of her complex medical care because so many docs are refusing Medicare patients. She relies on the haphazard care of a local clinic, and the generosity of local charities to cover her drugs.

    I have no idea how the government comes up with their reimbursement schedules. It makes no sense.

    Frustrating all around.

  3. great summary of challenges facing primary care. i am sure most of the time physicians (all of them, not just primary care) don’t decide on the basis of whether the marginal reimbursement for one established patient makes them money, but rather whether their schedule allows them to see the patient appropriately. at least i hope so.

    panda seems to imply that the diagnosis and treatment could be made without the labs and imaging more readily available in the er. i can only hope there was more to it than that.

  4. Excellent, well argued post. (Slightly biased re: chiropractic, but I guess that should come as no surprise to your readers.)

    Regarding your comment that some primary care physicians “are locked into the insurance mindset but it will only be a matter of time before medical doctors realize that many American retirees are not poor, need fairly detailed primary care, and might be willing to pay for it if they perceived good value for the money“:

    Be careful of this slippery slope. Yes, many retirees are not poor, but many more are, or at least they’d find it difficult to pony up the sums of money for the “boutique” medicine (or whatever you want to call it) you describe here.

    The economic model underlying this arrangement makes sense in the transfer of most goods and services, but should be implemented cautiously in situations involving services– like medicine– that are prohibitively expensive to many buyers. Alas, if more physicians adopted this free-market approach, fewer would be available to the rest of the population, and more of the elderly would end up like your “distinguished elderly gentleman” in the ED.

    (But you see, I mostly reject collectivist notions when it comes to the allocation of goods and services, especially as it applies to medicine where physician’s services are believed by many to be in a common pool that can be allocated by everybody but the physician.  Currently there is a high demand for physicians but a lot of this demand results from there being no penalty for seeing a doctor, at least financially, for most people.  As a result we are, as I have pointed out in other posts, ridiculously over-doctored with many of my patients being followed by a small platoon of specialists, for example, whether they really need to be or not.  And so far doctors generally try to meet the demand but at the cost of spending less time with patients and making everybody wait longer.   Maybe the elderly need less of the team-based doctoring where six different physicians try the impossible task of coordinating with each other and more of the individual type which may cost more per visit but avoids the need and the temptaion of the primary care doctor to farm everything out. 

    In other words, if there is a business model where people can make good money at it, primary care will again become popular and there will be more family physicians and internists to go around at the expense of, say, cardiologists, most of whose job is bread and butter stuff that any doctor should be able to manage.

    Will the poor get screwed?  Of course they will.  The poor are always getting screwed but most especialy when the government buys them off with the promise of some crappy benefits which serve only to keep them in poverty and dependence.  Number one goal of many of my poor patients?  To get on disability, the proverbial easy-street of the under-class.  Oh how they dream of the tantalizing life that could be theirs if only they could parlay nebulous back pain into the 900 dollar per month cash jackpot with Section 8 housing and food stamps.   If the government wants the poor to be seen by doctors they can pay the market rate…and perhaps tighten up a bit on what they will pay for because I gotta tell you (and I’ll detail this in a later post) a lot, a lot, a lot, (a lot) of what the government buys with its health care dollar is utterly wasted. 

    The key is for the United States to evolve into a nation that needs and uses less health care, not more, a goal that would be achievable except for the criminal lack of common sense in the way we spend money.-PB)

  5. And it promises to only worsen as older high volume (though variable quality)primary care docs retire and few new graduates are entering primary care practice. In our community most primary care practices are full, accepting few (and certainly not Medicare) patients; and those that are lucky enough to be in a practices are subject to the issues you describe well. The coming inablity of upper middle class Americans to find a primary care physician (concierge or other) will be the stimulus that incites a reorganization of medical care in this country, for better or worse.

  6. They are also encouraged to try anti-aging therapies including “natural detoxification,” chelation and “immune modulation.”

    @Brad, the best evidence shows that SMT is as effective as physical therapy or massage for acute, low back pain; it is not “more effective” compared to anything. Nothing else in chiro is supported by good evidence.

    As for vertebral artery dissection, it may be rare; but it is entirely unnecessary. The neck snap does nothing that cannot be achieved more safely. Therefore, the risk/benefit analysis produces an unacceptably large number (division by zero).

  7. Re: chiropractors practicing pediatrics, I wonder whether they are required to carry malpractice insurance. If they’re going to practice on kids, I would certainly hope so. And if they have it, I think our sometime friends the plaintiffs’ lawyers may take care of the chiropractors’ foray into pediatrics before too long. It would be nice for them to do something helpful once in a while.

  8. Panda Bear,
    You’re joking about the so-called benefits thing, aren’t you? What benefits? What HUD housing? Public housing has been shrinking in numbers of units since the eighties. And 900 dollars a month goes nowhere if one can’t qualify for anything else. Pay rent? Yeah, right. Get help getting educated to do something else? There is no help, and forget vocational rehab, another area that’s been reduced, and continues to be reduced.

    One thing you’re right about: the poor will get screwed, and in a free market system, that will continue. The people who use the system too much are those who can afford it, have insurance, or Medicare, and want the diamond treatment.

    The poor go to the ER because they have nowhere else to go.

    Do the poor figure into your ideas, or is that to be a separate issue for consideration?

    I’m not trying to be argumentative, but I can’t see how to fix one part of a system without considering the ramifications on whole sections of the population. It’s not like we’re talking about a crop of corn, or car production. Yes, we need limits, and the public needs better education and a little more discipline, as well as the limits of the human organism to fight the onslaught of natural forces, but at this point I see problems with both the free market approach and the completely bureaucratic socialist approach. It seems we need a system that makes room for both.

    I have no answers, but I have concerns, but I’m working on it.


    (You see, you are guilty of projecting your expectations for life on other people, particularly the indigent poor, none of whom have nearly the ambition to suceed in life to the level that most of the readers of my blog would claim.  Sure, you wouldn’t be happy with a measly little disabiilty check from the government (along with free health care, HUD housing, and food stamps) but I assure you this is the limit of ambition for many of my patients.  This is not to say that they don’t dream of hitting the lottery or otherwise coming into a large sum of money, and this is also not to imply that they are bad people because they certainly are not, only that they have been conditioned by life in the dependocracy to have small dreams, most of which revolve around looking for a way not to have to work at the kind of dead-end jobs which are the only kind for which they are suited.

    Look at it this way.  Do you think my typical twenty-five-year-old polybabydadic patient with four kids living on the public dole would continue this lifestyle if there wasn’t an advantage to it?  If the government didn’t give housing, food stamps, free health care, and small cash payments to single mothers this kind of lifestyle would have zero appeal because, except that we subsidize it, there is no advantage to it at all.  Likewise I have plenty of forty-year-old men who have hit the jackpot whose entire life consists of subsisting on their disability (usually for a distant back injury) and wiling away a productive day or two every couple of weeks trying to get extra narcotics from the Emergency Department. 

    Additionally, there is so much help out there to give people a head start that it would amaze you.  Anybody can borrow money, for example, from the government for any vocational program they have in mind from cosmetology to a medical degree.  It is, however, a lot easier to sit on one’s ass complaining about how tough is life than to do anything about it.  There is such a thing as self-reliance.-PB)



  9. rjaye,

    the poor do not go to the ER because they have ‘nowhere else to go’. they go to the ER because it’s ‘free’. they tell me all the time.

    ‘why didn’t you get an apointment in town?’
    ‘because they want me to pay them.’

    it is true that about one in ten of these patients arrived at the ER by bus or on foot, but most drove their cars and many have a whole bunch of tattoos and a cell phone and manicured nails.

    this is simple economics. if something of value is declared ‘free’, as emergency care has been done de facto under EMTALA, then the demand for it will skyrocket.

    try making food free and see how much is left on the shelves and see how many grocers can stay in business.

    panda is right. doctors take at least 11 years to make (college through residency). when we realize, as a group, that we have a very high value to our society then we might be able to turn the focus away from all the horrible things we do wrong, and focus a bit back on each individual, and each individuals responsibility to themselves, and their neighbors, to play both a financial and participatory role in their own health care.

    and obtw, as long as you wait for ‘the government’ to provide the ‘program’ or ‘plan’ to fix poverty, hunger, disease, or pick your malady, well, that’s how long you will wait.

  10. Oscar, I followed your link to Correct me if I’m wrong, but isn’t this doctor simply charging $1500/year for an annual comprehensive physical exam and the ability to call him at any time (as well as ECG, CXR, and “32 blood tests”)?

    What about the costs for other screening procedures? What about other radiology costs? What about hospitalization (does this MD have admitting privileges)? Does the patient have to purchase additional insurance to cover the fees of specialists? What about mental health treatment? Prenatal care? Prescription coverage?

    I’ll admit, $1500 seems like a reasonable cost for a year of immediate access to my primary physician, but I would imagine there are many additional “hidden” costs that are not described in this outfit’s promotional materials.

    Anyone else have any more detail?

  11. Superb post, PB!

    I’m a rural FP scraping by with a mostly Medicare and Medicaid practice. Few people have a clue how the physician supply problem will worsen with national health care and old farts like me hang it up.

  12. The physical therapy profession is continually challenged by chiropractors looking to expand their scope of practice. It is a very dangerous and expensive prospect for physical therapists to deal with. I did note in some comments that people still seek the manipulative care of a chiropractor. Well, there may be more to physical therapy than you think!

    Check out my response to this post at NPA Think Tank, with some recently published works exploring this issue. Awesome post, very important issue to me, and the physical therapy profession!

  13. re: chiropractors.

    I had lower back pain so severe I couldn’t pick up my infant son for hours in the morning. before I taught him to slide down the stairs, we would literally be trapped upstairs. I was afraid I would drop him! as I moved and stretched, it got a little better, so at least I could pick up my son, take him down the stairs, and grimace through my day.

    I saw a couple dr’s. told them exactly what was going on…One looked me in the eye and sayd “you are just getting old…deal with it”. I wasn’t 30 years old at the time.

    It wasn’t until I saw a chiropractor and he took x-rays (no insurance so he waved the x-rays and inital exams) that I found out a back injury 10 years before had eventually caused one disk to be 90% degenerated. I had bone hitting nerves…and that was causing my pain.

    (I’m going to call bullshit on this.  There is no medical doctor on the planet who, in the face of your excruciating pain, would skip to the diagnosis of old age without working you up as thoroughly as we do anybody. There is no diagnosis of “old age,” except by exclusion, and a lumbar-sacral series (x-ray) is not that expensive to take or have interpreted.  What probably happened is the chiropractor did a sloppy film, over-interpreted it, and now has you hooked for regular adjustments for the rest of your life even though most acute back pain resolves in six weeks with no intervention except NSAIDS and a little bit of back rest.  -PB)

    In a few weeks, I experienced waking up not in severe pain. I also noticed my headaches were fewer. Other dr’s just said I’m prone to migraines. I never connected them with my back pain…but the constant adjustments really helped.

    (Sixty-four-thousand dollar question: Why did it take a few weeks?  Think about it. -PB)

    Say whatever you want about how shakey it is…for many of us it is the only thing that works. YES I hear the Dr’s are overworked… but when no one will listen…what are you supposed to do?

    While I’m at it…I have a dr now who despite a long list of related or unrelated symptoms, was only worried about a hernia that frankly wasn’t bothering me. I am getting sicker and sicker but she tells me “don’t worry about it”. I’m not sleeping (but tired all the time) so all I can do is worry. she said my blood tests were “normal” but wouldn’t do or tell me anything else. I saw her exactly two times and can’t get the staff to pick up the phone. no machine. no service. and they like to sit and talk and let the phone (yes, I’ve SEEN it)ring.

    She’s so overworked she has loads of time in the middle of the day to run to the health club and workout. (again, I saw her there, on more than one occasion. before she banned me from working out because of my hernia)

    (Hang on.  She runs the health club as part of her job.  In other words, she negotiated a contract with (obviously) limited hours and the perq of being able to work-out during the middle of the day. Lots of women doctors negotiate contracts that give them more time for their families for example (at the expense of their earnings, of course).  What you are suggesting is that she should have no life except listening to your complaints.  Do you think I give my phone number to my patients and say, “Call me anytime you have a problem, day or night.”  Of course not.  There has to be a limit and the reimbursement for general medicine is so low, primarily because neither the insurance companies, the government, of the patient value it, that there is very little incentive for your doctor to be a slave to her practice. -PB)

    So while I know alot of dr’s are good (I’ve had the pleasure of having 2 amazing GP dr’s in my life and one amazing Ped for my kids) there are also many bad ones who don’t care.

    Maybe the answer to the Dr shortage is having more NP’s to do the Day to Day stuff. let the Dr’s work on the complicated stuff. My experience with NP’s is always positive, and they do seem more caring and open as a group.

  14. Two things:

    The “poor” – I currently work at a homeless shelter, and there’s one guy who sleeps there, but drives a $40,000 car (I originally thought he was an employee). I asked my boss why – and why doesn’t the “homeless” guy sell the car – and my boss said, “Status. It’s better to sleep in a shelter, and drive a cool car, than work for what he wants.” I was flabbergasted.

    Bad back – I had a back operation at 19 and have lived with back problems for the rest of my life (I’m 46). The last time I went into the emergency room (poverty, with a bruised disk in my neck) I demanded an immediate MRI, but the doc overruled me, demanding an X-Ray, first, etc. He wanted to check everything. It cost me more money but, listen, Docs don’t mess around:

    I call bullshit on Ladynoopie too.

  15. Well, it wouldn’t be the first time I projected, yet I think you’re generalizing a bit much. I’m sure you do run into people who mooch off of the system, but I’ve also worked with people who had no other resources, and no other options.

    The hospital I worked at started a front desk triage practice, and swerved those with non-emergencies into a 24 hour clinic where the patients were responsible in part for the bill. It operated like a walk in clinic. If people didn’t like it, well, they had a choice. The medical care was offered. That’s one way to deal with it.

    And as for all the money out there available for vocational programs, no, it isn’t. I worked for several years as a “consumer” advocate (yuck, I hate that term) helping people get heath care, housing, vocational assistance, etc.

    Maybe we’re on opposite ends of this issue, but I’ve seen that in twenty years things have gotten worse for the poorest people. I am not denying that regulations and screwed up systems and lack of compensation for GPs need to change, and reflect the worth of those people. At the same time, money can’t be used to reflect the worth of those people who end up at the bottom of the scale either.

    As for waiting for government to do something, I don’t want government helping those who are capable–I would like to see our government to help those who can’t help themselves.


  16. My anecdotal evidence of chiros not knowing what they don’t know:

    Had a 20 y/o male with h/o renal stones and ONE kidney come into the ED with complaint of colicky LBP x 1 week. Had been going to the chiro for the last week for what the chiro presumed to be lumbar strain. Obviously, his treatment didn’t work and the kid comes to us when his pain is unbearable. He is now in acute renal failure and CT scan shows 4 stones in his one good ureter! On top of that he has urosepsis and is severely acidotic, so now he’s in the MICU.

    F*ing ridiculous.

  17. One of my best friends used to work as a primary school teacher. Then she quit to help take care of her mother, who was developing Alzheimer’s, and then later her sister, who developed Crohn’s. Being a primary school teacher was not a particularly high-paying job to begin with, but she had laid away some savings by being extremely frugal. These savings didn’t last past taking care of her mother and sister, however.

    Now she’s in her sixties, and has a problem with chronic respiratory disease. She also has no savings, no assets beyond her house, and relies on Medicare. Your payment-based system would appear to offer her the option of “too bad, you’re screwed. Tough luck if you die.”

    If she were the only one, the world would shrug and move on. She isn’t; there are tens of millions of people in America in similar situations. So what precisely do you think should happen, there? How does your proposal make any room for these people? And, if the only treatment option for them is to use up their own money and then get nothing, while other people visibly get the same kind of life-saving medical care they need (note, we aren’t talking luxury goods, we are talking basic to survival!) — then how does this not foster an even greater erosion of the middle class as savings go away, and then seething anger in a growing part of the population? There are wider political repurcussions to that sort of thing, as well.

    So? What IS your answer, then?

  18. Right on as usual!
    Excellent writing, great analogies. I recommend you to all of my friends and coworkers. 15 year paramedic here, and while my experience and perspective are different than yours, I find myself in lockstep with you on most of the opinions you express. The #1 reason and basis for virtually every problem in our healthcare system today: lack of personal responsability. Period.

  19. Would this chronic respiratory dz be COPD?

    As a primary school teacher, she has no obvious occupational exposures to asbestos or coal. She isn’t a good candidate for farmer’s lung.

    I’m just wondering if this case is COPD in a smoker.

  20. I have always maintained that good health cannot possibly come from little brown plastic bottles. We must begin to coach patients, and lead by example, to be more healthy. Setting the example by maintaining some semblance of physical conditioning and health, not being grossly overweight, is important.

    The other issue is the reliance on medications for things that are the result of an unhealthy lifestyle. We now, or have had for years now, have “Syndrome-X”. This is a hoot… high blood pressure, high blood sugar, and cholesterol/triglyceride issues. Usually, patients with this will be obese or overweight. They’re generally leading sedentary lifestyles, and without realizing it, feeding the problem by eating too much of all the wrong things.

    Typical patient goes to the doctor with this? Lisinopril, lipitor, and metformin, with lip service played to exercise and diet. Where does it all lead? Without meaningful changes in this person’s lifestyle and habits, full blown diabetes, heart attack or stroke, diabetic neuropathy, and disability. Pills or no pills, this person is unhealthy because of what they are doing to themselves. They will decline until they change their ways.

    Want health care to be cheaper? Don’t use it… don’t need it. Be healthy, and watch out for bad habits, we all have them.

    Weirdly enough, the sickest I have ever been in my life, nearly died, was while reporting to a surgeon that had done a lappy appy on me a week before that I was not feeling well, and something was wrong. For a week I told him, and told him, and he said, “You’re back to work too soon. I can take you back out of work.” Oh, and a second lapp the night after to remove 20 ounces of blood and other stuff he had no idea of the origin. Said he was sorry, as it may have been left in there during the procedure. No hard feelings, really. It happens.

    Finally, as I poked him in the chest and threatened to fire him, I said that I was going to die if nothing was done. I woke that morning soaked in sweat and felt like I was dying. I had pain in my right lower quadrant, and was swelling.

    CT showed abcess and peritonitis, e. coli infection… 7 weeks of i.v. antibiotics. 295 pounds when I had the surgery. Three weeks later I get out of the hospital for the third time… 248 pounds.

    Not mad about the first two, the appendix was nasty and had to go. People bleed during surgery, and nobody is perfect. If I was mad, it would be about being allowed to get sicker, and sicker, while telling him something was wrong.

    In the end? 65,000 dollars worth of medical costs, about 15,000 dollars in lost wages, and that was a “nuisance lawsuit” according to a few attorneys, as I was living a normal life in the end of it all. And the damages were not that bad…

    If I backed my truck into his BMW and did fifteen thousand dollars in damage, you can bet he’d be chasing me around with his hand out. Of course, the scumbags at the insurance company have subrogation rights against a malpractice award. So, I’d have had to sue for big bucks to pay them and a lawyer, and be left with anything for myself. To hell with it, I am glad I am healthy…

    Truly weird though… to go to a doctor and insist something is wrong. He ignores it, “back to work too soon.” Go see my PCP for work check-up, and he’s all over me… I have white coat hypertension… always been high when at the doctor… since I was a kid. It’s normal at home, but he went high and low to get me to take lisinopril. Now my blood pressure is 90 to 100 over 50 to 60 when I wake in the morning. I get headaches, and sometimes feel dizzy, and the cramps when I exercise are sometimes unbearable down the inside of my thighs, Adductor muscles. Exercise capacity is there, with a prolonged warm-up period.

    “Nothing wrong, no complaints? We’d better run some tests!”
    “Don’t feel good? Sweaty? Weak, pain? You’re fine, just back to work too soon.”

    Go figure…

  21. As a practicing physical therapist I am always amused by studies and statements comparing “physical therapy” and “manipulation” for treatment of back pain. Being well trained to perform spinal manipulation, and using them clinically, I can say honestly that I often wonder what exactly is being referred to by “physical therapy” in these studies. Manipulative therapy is one treatment used to treat low back pain. Chiropractic Medicine? Nope, manipulative therapy… Grade Five mobilization. Seems to reduce low back pain nearly immediately in most patients.

    There are some questions to be answered beforehand… mainly to screen for medical problems that might be causing the pain. Also to assess the amenability of the patient and the problem to the treatment. If they have a high pain fear behavior level, pain for more than two weeks, true sciatica, it’s going to be a difficult situation to do manipulation and expect it to work.

    Because it is a “physical” intervention, and not a “chemical” intervention, it is not the same on every patient. Some are different physically, and the pain is not always coming from an entity that will respond to joint mobilization or manipulation. It is not the same as drug therapy, which should (within limitations) respond the same in the vast majority of patients. The source of the back pain is also a huge factor.

    However, “subluxations” are not in our vocabulary, and I have never corrected one in the years I have been using manipulations. I do not know what they are, in the spine that is. I am familiar with subluxation of the shoulder in patients with anterior shoulder instability. Other joints can sublux as well, although I am not familiar with the concept of kidney failure resulting from this… sublux the spine enough and I suppose paralysis will occur….

  22. @SexPanther,

    Chiros have their own collections of anecdotes about mis-diagnosis by MDs. I think it is better to observe that chiros can go to school for 4 years, take a test, and be licensed to play doctor without ever seeing an unhealthy person.

    Chiros’ “clinical education” is largely (or solely) limited to healthy relatives, friends and acquaintances whom the cajole (or pay) to show up for examination. Nothing of the sort can be said of licensed MDs.

    By the way, one chiro told me this is how they learn to recognize healthy people, too!!??

  23. @Miami Med —
    No, she has never smoked in her life. She did grow up in a coal-mining town, very near the mine, and her father was a miner; I don’t know if that could possibly be enough exposure, or whether that kind of exposure in childhood would manifest itself five decades later. But she’s never smoked.

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