The Brazen Cage and other Medical Thoughts

(I get a lot of questions and comments by email and I thought I’d share some of them with you folks. -PB)

Hey Panda, who are you going to vote for in the 2008 Presidential election?

Good Lord, is it already time for another election? It seems like I have only just recovered from the horrors of the last one although I do remember with great fondness when the Bush National Guard Letter turned out to be an obvious and amateurish forgery which lead to the subsequent collapse of the Kerry campaign’s raison d’etre.

Good times.

Seriously though, I have not really been following the campaign. I will say that Health Care is not that big of an issue with me, at least not in the sense that I burn with a holy fire to insure the uninsured. I know too many of them to really buy into the notion that they have some kind of inalienable right to my labor. I believe in charity so I have no trouble with the idea of providing aid and comfort to the poor but come on now. Except that there is very little incentive to do it, most people, most of the time, can afford most of their medical care if they got their priorities straight. Best Buy, for example, was packed on the day before Christmas, absolutely packed, with people going into debt for useless consumer electronics. A couple of video games, a Wii, an iPod.  Pretty soon we’re talking serious money that people will not, repeat not, even dream of spending for something as useless a visit to the doctor.

Can’t spend money on that shit. Oh no. Everybody knows that medical care just flows effortlessly out of hospitals like water out of a tap.

So like I said, I’m not excited about health care reform as a national issue. Not to mention that giving it away for free, about the only kind of “reform” that is going to be able to run the guantlet of lawyers and other special interests, will do nothing to solve any of the structural problems that make our system so expensive.

My big issue is national defense and fighting the islamofascists so despite being a social conservative, I’m probably going to back Rudy Giuliani. I’m not looking for perfection, you understand, just someone whose heart is in the right place when it comes to killing terrorists. All the other issues? Just fluff mostly. Or schemes to transfer more of the personal wealth of those who earned it to those who not only haven’t but feel entitled to it. That’s what most of politics in the Western world has come down to unfortunately, although the United States is probably one of the last of the Western Democracies where people will get excited about something other than extending cradle-to-grave social benefits.

I’d certainly rather see my tax money going to build and operate a Carrier Battle Group than to enable somebody to get their asthma medications for free rather than having the cost eat into their cigarette money. Aircraft Carrier? Useful in its own right as well as being the modern equivalent of a cathedral if you can stretch your mind around that concept. Free asthma medication? Useful, of course, but unlike national defense, protecting citizens from the consequences of their bad decisions maybe shouldn’t be federal policy. I favor health care reform to take away free medical care from as many people as can pay for it themselves while continuing to support the people who obviously can’t. At the very minimum most people, most of the time, should be expected to pay for most of their primary care while reserving health insurance for catastrophic events. That’s the kind of market force to intoduce into the system, the only kind that will work which is for people to realize that going to the Emergency Department with a chief complaint of “My butt is sweating” is not a good use for their own money. Funny how nobody cares about money if they’re spending somebody else’s.

So I haven’t exactly caught Ron Paul fever. I like the guy, of couse, and he would be a perfectly acceptable candidate despite his opposition to the war in Iraq, but we need a gunslinger in the White House, not a doctor. Naturally, as I am a Broken Glass, Yellow Dog Republican (I’ll crawl through broken glass to vote for the Republican candidate even if he’s a Yellow Dog) I’ll vote for whomever the Republican Party nominates. I think Vice President Cheney is probably the best man for the job but he’s not running, more’s the pity.

So Panda, do you think it’s worth it…medical school and residency I mean?

God, I hope so. I really hope so. But every now and then I have some doubts, doubts that are probably just the residuum of almost seven years of medical school and residency with nothing to show for it but debt, financial ruin, and the sure knowledge that it is this or nothing. I mean, on an intellectual level I know it is probably going to be all right. I have less than 18 months left of residency and I can just about see the faint glimmer of light at the end of the tunnel which represents a time when we can start chipping away at our massive debt and maybe putting some black on the old family balance sheet. But it is eighteen months in the permanent temporal-financial crisis known as medical training which paradoxically seems like either an eternity or the blink of an eye depending on whether you are dreading either another year of debt or the all too imminent end of your ability to hide behind your training status as an excuse for not knowing something.

It’s a hot and cold, love and hate kind of thing. I like being an Emergency Medicine resident but I hate being a resident. I like having the support and guidance of my attendings but I hate that I have close to 12 years of higher education and am making about what I made as a starting Civil Engineer almost fifteen years ago. I worry about the future but on the other hand, as my wife points out, we are in it (and in it good) with no choice but to make a success out of it because there is no other option now. We have burned every bridge, played-out every strike, staked the farm, mortaged our souls, and robbed (no, mugged) Peter to pay Paul. We are in a cage and only time will tell if the bars are gold or common brass.

And no, I wouldn’t do it again if I knew back then what I know now. Don’t get me wrong, medicine is a pretty good job. For my part, I see a fairly broad range of patients, most of whom I like, with every possible complaint you can think of, from the ridiculously pedestrian to the spine-chillngly grim. We also get plenty of respect as physicians, even as residents, so no complaints there. I like it just fine but there is just so damned much of it. I occasionally get a normal weekend off and it is amazing to think that I once took this kind of thing for granted, not having to do anything and more importantly, not worrying about things. You see, I used to be a Structural Engineer and felt pretty good about it most of the time, especially as I was self-employed and within the confines of the need to produce work for my customers did entirely as I pleased.

As to how it feels to practice medicine past residency I can only profess ignorance and remain mute. But medical training is tyranny, a necessary condition for the most part but still tyranny and while I’m glad I did it and look with optimism to the future, I am, in fact, almost done. If I had known nine years ago when I first got the idea in my head to go to medical school (and believe me it seemed like a crazy idea at the time) what it was going to be like I would have laughed and forgotten about it in short order.

“I’d like to go into Emergency Medicine but I don’t think I’d like all of those patients who aren’t really sick. What do you think?”

Grow up. While I’m sure that there may be some physicians whose entire day is spent managing patients on the knife-edge of disaster, where every decision they make is fraught with peril and only made after the ramifications are weighed in their lightning-fast minds, most of us spend a lot of time with patients who are either not very sick or so chronically sick that you have a little bit of time to make decisions. Everything is not an emergency, in other words, even in the Emergency Department. This is not to say that we don’t see a lot of really sick patients but the idea of having residency training is to make even the incredible so mundane that one day you arrive at the point where, when confronted with a dialysis patient in florid congestive heart failure and respiratory distress from cocaine use, you yawn, take the appropriate steps, and wonder if you have what it takes to handle a really complicated patient.

But apart from the obvious abusers of Emergency Services, you are going to see a lot of colds and vague abdominal pains that turn out, after the five-thousand dollar work-up, to have been nothing. You just have to deal with it. It is the steady parade of minor complaints made possible by that Mac Daddy of unfunded mandates, EMTALA, which keeps the doors open and the lights on for the twenty percent of patients who really have medical emergencies. In other words, if it wasn’t for the minor complaints most Emergency Departments would be sleepy little affairs where most of the employees spent most of their time sitting on their hands except, of course, when something big came in. But the four or five big traumas we see every shift or the ten or so bona fide medical emergencies that need immediate management will not keep the doors open at the current levels of staffing. If we turned away the minor complaints (which we could do in theory under EMTALA) or quickly admitted the ones who were really sick but didn’t need any acute intervention, Emergency Medicine as a specialty would be like pediatrics, that is, it would be filled with people for whom the specialty was a special calling and who did it even though it didn’t pay that well.

I rise in support, therefore, of the minor complaint. Chronic pain? Fibromyalgia? Mild asthma exacerbation? Lips tingled a little after eating shrimp but feeling better now? Upon this sturdy foundation is our specialty built and it is the demand for Emergency Physicians, doctors who can handle everything from a common cold to a traumatic evisceration, that keeps salaries at their current level. Like every other specialty, Emergency Medicine is a volume business and the volume has to come from somewhere.

It also helps to keep in mind that most people are fairly rational and, while you may have the occasional patient who makes you scratch your head and wonder how they manage to breath and wipe their ass at the same time, most people will not sit in the waiting room at two in the morning waiting for several hours to be seen if they weren’t concerned about something. In other words, something about their vague chest pain worried them enough to call the ambulance or drive through the snow to see you. If you keep this in the back of your mind you will avoid the dangerous tempation to minimize your patient’s complaints. I can’t tell you the number of times the chief complaint and initial presentation masked a terrifying condition that made me glad and relieved that I not only hadn’t missed it but may have had a part in saving the patient’s life.

A lot of times the big level one trauma coming in turns out to be nothing. It’s the quiet little lady in the distant corner of the department who may be bleeding internally and require your complete attention.

28 thoughts on “The Brazen Cage and other Medical Thoughts

  1. Oh my, dear Panda Bear MD.

    I’m afraid this one little statement may taint how I read your posts, past and present.

    “I think Vice President Cheney is probably the best man for the job but he’s not running, more’s the pity.”

    I had failed to see the ‘Broken Glass, Yellow Dog’ in Panda Bear MD, pity indeed.

    Although, I will still enjoy reading what’s on your mind, present and future.


    (Mr. Cheney is the most intelligent man in Washington.  Period.  -PB)

  2. Mr. Cheney is quite possibly the most evil man in Washington. You know that Will Smith quote about Hitler, how people always think they are doing the right thing even when they’re not? Well, I think Dick Cheney might be the sole exception there. Not that political corruption is unique to the Bush administration, but the ridiculous flaunting of the law by this President is quite ridiculous. From things like the Plame affair to the illegal wiretappings, they’ve probably done more to ruin the country since the idiot Democrats decided to go into Vietnam.

    (Your entire criticism of Mr. Cheney is based on nothing except the echos of the ravings of the Daily Kos crowd and is entirely in keeping with my assertion that civil debate is impossible nowadays on almost every subject.   Rather than, for example, elucidating why you believe it to be wrong to intercept messages from terrorists you jump to the conclusion that Mr. Cheney (who I have actually met many years ago before he grew his horns and assumed the Throne of Satan) is the very incarnation of evil. -PB)

    If we can impeach Clinton for lying about a blowjob, we can certainly impeach these criminals for their multitude of crimes. I’m not even going to go into Iraq (which a lot of dems voted for too). Obviously this is just a pipe dream, but I’d like nothing better than to see Bush in handcuffs in front of a court for violating the constitutions numerous times (for treason).

    (You see, conservative as I am and as staunch a Republican I don’t hate anybody in politics and do not let political setbacks drive me into a frenzy of hate and silly revenge fantasies.  “Multitude of crimes” is an exceedingly silly formulation to describe the sausage factory that is domestic politics and the realpolitik required by diplomacy and fighting a war.  It’s one thing to be an advocate of various causes but your political bias and emotional needs shouldn’t  cloud your judgement.  Most political debate in this country, unfortunately, is on this level and waged by people who don’t really know anything at all about the subject for which they have such deeply held opinions. 

    Valerie Plame.  Come on now.  As if anybody outside the beltway or not a rabid political junkie even knows or cares about a subject which even the most rabid partisans cannot explain. -PB)

    In any case, I completely agree with your assessment of the health care system. Nothing that someone else has to provide should be free.

  3. I think it was in the epilogue of Intern Blues — the second running a few years ago — where medical training was likened to a bad dream that’s horrible when you have it, vivid for the next short while, and then just kind of fades and leaves you with a sort of, “Yeah, I don’t really remember some of it, but I’m pretty sure it sucked at the time. But it’s fine now.”

    Wondering if maybe you’ll decide that you just may have done it all again, given the choice, once you’re past residency. Then again, I’m also a premed looking towards EM, so the “would you do it again?” bit always gets my attention.

  4. Panda,

    I’d like to explain further if I can:

    wrong to intercept messages from terrorists

    The problem with this is obvious. If you knew the person was a terrorist, I would have no problems with wiretapping. The problem with bypassing the legal system, and taking it upon themselves to randomly wiretap people leaves it open to huge violations. If they only want to do it on terrorists, why are they so against court supervision? If they want to wiretap a US citizen, they should get legal permission from a judge. If they can’t show the judge why they want to wiretap someone, they shouldn’t have the right to violate that person’s privacy.

    alerie Plame. Come on now. As if anybody outside the beltway or not a rabid political junkie even knows or cares about a subject which even the most rabid partisans cannot explain.

    Come on Panda, just because the average joe isn’t aware of something, doesn’t make it less egregious. If you don’t think this qualifies – fair enough. What about the “independant” oversight board that did not report a single intelligence abuse during the 5 1/2 years of the Bush administration, and then they admitted there were numerous cases of violation of the law? You can’t rely on someone to police themselves, that should be obvious to you. Just like you say that you claim that an average person won’t be frugal when spending someone else’s healthcare money, someone won’t willingly check their own power.

    Not a big deal? Fine. What about the secret CIA prisons and tapes that are destroyed of interrogations? Some of these people are US citizens, by the way. I wouldn’t have half as much problem with these interrogation techniques if they were tried on people convicted of something. And then in the case of Padilla, the government just claims that “You can’t believe Padilla when he says we tortured him because he’s crazy from all the things we did to him.”

    What about the attorney firing controversy? There is literally a huge list of violations. This administration is a black spot on US history.

    (Again, your arguments are straight from the Daily Kos and reek of the typical conspiracy theories without even an attempt to look at anything either critically or even from the much vaunted, usually ingnored “other point of view.”  In other words, rather than, for example, asking yourself why it might be necessary to intercept phone and email messages from people who may (or may not be) associated with terrorists you fall back on the, “Better Chicago burn in nuclear fire than we take even the slightest risk of violating any of your rights in even the most trivial way” mode.

    I mean, the government intercepts billions of email communications every day and probably millions of voice messages looking for words and combinations of words that might lead to unravelling a very real threat and you’re concerned about what, exactly?  That the NSA cares about your radical views on this subject or another? That you’re mundane conversations with your friends are hot national security topics?  You have the particulars of the NSA’s signals intelligence efforts wrong anyway.  For my part, I would be shocked to learn that we weren’t aggresively monitoring signals of all kinds.  It would be inconceivable to me that we could expect to fight a war against an enemy that counts on us not violating their rights without the ability to eavesdrop at will anywhere in the world including in our own country.  I also think it is the hieght of irresponsiblity for the particulars of this “front” in our complex war on terrorism to have been exposed to our enemies.  There is no need to play fair, the constitution is not a suicide pact, and we’ll just have to bend the rules a little here and there.  There is no slippery slope here.  Signals intelligence does not lead to repression.  It’s just part of warfare.  Now, if you can make the case that the NSA is feeding intercepted signals to individuals for political or personal gain then go to it.  But you’d look pretty silly shrieking about your rights when a major nuclear, biological, or chemical attack slips through our defenses because a vital part of our defensive plan is hamstrung by the requirement that the ability to use time sensitive intelligence depends on the whim and the long deliberation of a judge as if we were only  concerned about monitoring a two-bit Mafia hood.  Intelligence is a puzzle made up of thousands of pieces of information, not one big breakthrough where the terrorist announces, in the clear, “Hey, Hassan, are we all set to bomb Times Square next Tuesday?”

    The point is that you are a little bit of an extremist and unable to be a little flexible even when necessary.  Also that the lack of knowledge of our public about warfare, intelligence, and it’s requirements is absolutely criminal. -PB)

  5. The point is that it is impossible to completely defend our national borders and always arrest those who plan on doing harm to innocent civilians, with or without bending the rules a little. This is a shocker, but the fact is that you cannot go through life without getting a (figurative) black eye once in a while. No nation is totally safe just as no individual is totally safe.

    The concern is that when we look the other way when our government ‘bends the rules’ (or breaks them, depending on your point of view) is that we are not getting a good deal for what we are giving up. In other words, we may not be preventing enough acts of terrorism that -couldn’t- be prevented without illegal wiretapping and waterboarding and lack of due process. What we are giving up is quite dear and even with giving it up we’re not totally safe, so the question is what are we giving up and how much safer are we for having given it up? You might say that preventing just one act of terrorism that wouldn’t have even killed anyone is worth living in a police state. Or you might say that you’d need perfect safety before you tacitly agreed to have your phone calls tapped once in a while. It’s a matter of personal preference and a decision based on relative risk analysis.

    This is a much greyer point of debate and not one well-suited for sound bites or talking heads. Personally speaking my values place liberty higher than safety. As a side note PBear, it’s unfair to call someone’s concern of illegal wiretapping trivial – it stifles free discourse and creates an environment of fear just as medical lawsuits stifle clinical decision making and create an environment of fear. Illegal wiretaps may prevent some planned violence from occurring that couldn’t be prevented with legal wiretaps. A give and take, you see, but the problem is and has always been is the question: is the giving more or less than the taking?

  6. In other words, rather than, for example, asking yourself why it might be necessary to intercept phone and email messages from people who may (or may not be) associated with terrorists you fall back on the, “Better Chicago burn in nuclear fire than we take even the slightest risk of violating any of your rights in even the most trivial way” mode.

    That is fear mongering and really an unfair characterization of the argument. You are basically claiming that the population should not expect our fundamental rights to be respected because something bad might happen. The problem comes with ‘may or may not’ as you said. Really, if they do believe someone is conspiring with terrorists, why is it too difficult to show their evidence to a judge and get a legal wiretap? They don’t even have to do it right away. If in the case that the government believes that time is of the essence, they are allowed to wiretap before they get permission – as long as they show evidence in an reasonable amount of time afterward. Why is this not enough? What exactly are they doing that they do not want to abide by this law?

    There is no need to play fair, the constitution is not a suicide pact, and we’ll just have to bend the rules a little here and there.

    The constitution is not a suicide pact. The bill of rights is designed to protect the people against the government. Bending the rules is one thing – flaunting and ignoring them completely is quite another. Invading privacy in case of an emergency and getting judicial approval afterward is bending the rules – and one that is reasonable. Ignoring it completely and and unilaterally deciding to wiretap people is completely something else.

    Actually, I beg to differ here. Repression does not mean opening up gulags and sending people there. No one is suggesting this, but freedom seeps away slowly and I don’t see how extra-judicial renderings, wiretappings and other methods are anything other than the methods of an oppressive administration.

    But you’d look pretty silly shrieking about your rights when a major nuclear, biological, or chemical attack slips through our defenses because a vital part of our defensive plan is hamstrung by the requirement that the ability to use time sensitive intelligence depends on the whim and the long deliberation of a judge as if we were only concerned about monitoring a two-bit Mafia hood.

    You know what would make us completely safe? If we had no rights whatsoever. No matter what you do, you can always do something else to be safer. Always. The whole damn point is to find a compromise with the maximum amount of safety with the minimum surrender of rights. If you want to live in an environment that is completely safe, you shouldn’t live in a free society. No matter what we allow, there will be rights that you can give up to be more safe. That doesn’t mean that we should stop the ‘shrieking’ and just decide that that’s the way we want to live.

    The ‘whim and long deliberation’ that you mock is one of the central tenets of our government – to stop one part of it from being tyrannical. This is something that some people seem to accept only in the abstract.

    The point is that you are a little bit of an extremist and unable to be a little flexible even when necessary.

    I would say that those who are easily willing to give up their rights for some dubious benefits are the ones that are extremists. First you accuse me of not engaging in proper discourse, and then you follow it up by calling me an extremist. If you really believe that, it’s fair enough, but I don’t see how I am inflexible at all. Of course you’re going to have to give up some rights in a time of war, but that doesn’t mean you have no rights and an administration can just decide to usurp whatever legal process that they want.

    I respect your opinion and love your blog, but I just cannot fathom your politics.


    (Ah, so you see that the issues are much more complex with greater nuances than calling our elected leaders names and impuning their motivations.  It is the idea that President Bush has any sinister motive in authorizing increased signals intelligence that I am arguing and where you are inflexible and incapable of considering anything other than your knee-jerk reactions.-PB)

  7. Err oops. I messed up on the italics last post when quoting you. Feel free to correct if you can to make it easier to read. Sorry about that.

  8. Dear Panda,

    If your wife ever kicks you out, I will take you in. Keep up the great work. Common sense is hard to find these days. You are a breath of fresh air!

  9. PB- Ill agree with you that Bush and his administration did not order wiretaps to support the evil republican cabal, or to give information to his illuminati masters, or any sinister motive. However, can you really argue that its “just part of warfare”? Last I checked, the US government is not supposed to wage war on its own people. If they want to wiretap a US citizen, they should, excepting a clear and present danger, have to get a court order. If they want to use their secret intelligence court, fine, good for them. But seperation of powers is necessary so that the people doing the wiretapping are not the same people that decide if it is necessary and appropriate. Its an obvious conflict of interest.


    (Again, this is a perfectly legitimate opinion and a far cry from the “McBushchimphitler must die” rhetoric of the extremists.  But reasonable people may disagree as to what constitutes a reasonable danger.  The Bush administration is certainly worried about another catastrophic attack on the United States, say 30 kilos of Semtex detonated in Grand Central Station or a couple of canisters of Sarin released in a major hospital and feel, legitimately in my opinion (see, in my opinion, not an attack on you or your opinion), that the traditional mechanism of authorizing domestic eavesdropping is too slow to be effective in modern counter-terrorism operations, especially considering the stakes of missing something important.  I don’t necessarily see any conflict of interest as the NSA and the end-users of the intelligence have nothing to gain personally by having timely access to it.

    On another note, we give up our rights for safety all the time.  That’s the whole principle of the rule of law.  We sacrifice a little of our absolute freedom to do anything we please (anarchy) for the benefits of enforcing limits on our behavior.   The balance is the thing, and in our case we have more of a balance towards individual liberty over collective security but it’s just a question of degree.  I’m not accusing you of this but there are many who complain mightily about giving up some nebulous freedom to not have their cell-phone conversation intercepted if they repeatedly call a Jordanian phone number known to be an Al Queda safe house but actively work to surrender their economic freedom (the requirement of high taxes to pay for social programs) and their freedom to own weapons (the ultimate freedom against tyranny) for the safety they think this will afford them.  (The safety of not starving to death and not having someone go crazy shooting up a mall, I mean.)

    Again, there is no slippery slope.  Detaining a thug like Paddilla, a man who despite the big, bad government oppressing him has a crackerjack legal team protecting his rights, is not going to lead to you being “disappeared” because you voted for Kerry.  -PB)

  10. Also (sorry for the double post), if you did not have a family to support, and were younger (ie, just coming out of college) would you go into medicine again?


    (No. -PB)

  11. Nicely written, Dr. Bear, but I am left curious as to your philosophy, or train of though at the least, involving where our country should spend our tax dollars. For your post, I am left to infer that you believe by starving needy citizens of their medicine that their children and close family members will stop the habits that led to the given illness?

    (Did you read my post?  Most people, most of the time, can afford most of their medical care.  And they should mostly be expected to do it and could do it except that medical care is not a high priority for most people, most of the time.  Starving needy citizens indeed.  By your reasoning, if I don’t provide every necessity of life to everybody all the time I am starving them.  As to whether they stop their habits that lead to most (and I mean most) of their health problems, why is this your problem or mine? Or, to put it another way, why should you and I pay to subsidize somebody’s cigarette habit?  Every time you insist on paying for somebody’s asthma medication so they don’t have to choose between cigarettes or their albuterol you are subsidizing their bad choices.  If they prefer that cool menthol flavor and coughing up pieces of their lungs to their medications that should be their lookout. -PB)

    Well sir, don’t you think that is just too sugar-coated of a thought? Do you honestly think that will work? Personally, I feel that it would end up hurting so many people and I think much more would be needed to change culture.

    Possibly more government intervention via education or just raising prices on unhealthy foods would solve the problem. Not sure though. Maybe you could devote a post to it, please?

    (No no no no.  The solution is less government intervention, not more.  Let people fend for themselves as much as possible and they will start making intelligent decisions.  Most people are not stupid and will mostly make mostly rational choices.  Currently many people make what we consider bad decisions because there is no social or financial penalty for making them….or these decisions are rewarded. (Have an illegitimate baby and win welfare benefits, for example).  -PB)


  12. PB, I’m another reader who agrees with your viewpoint, especially about Dick Cheney. One of the things that has always impressed me about him is how he maintains his composure and low-pitched voice during interviews when he is asked the most inane and insulting questions. It’s very satisfying when a reporter rambles on with a loaded question designed to imply guilt or second guessing and Cheney’s answer is just “No”. Brilliant.

  13. (Joe, like I said, I don’t allow the Daily Kos-type toxic spew that passes for political discussion on other blogs and most of the media on my blog.  Rephrase, rework, and try again if it’s important that you get your point across:  Comment deleted. -PB)

  14. I have no idea what the “Daily Kos” is.

    There is a reason why ad hominem is not a valid argument form. I only made one point- if you cannot address it, that’s not my problem.

    (I don’t allow ad hominem attacks on our elected leaders.  Along with convoluted and ridiculous conspiracy theories, I am sick of this sort of thing and, while I allow all manner of criticism, bad language, and contrary opinions, I only ask that these be well expressed and free from the usual knee-jerking.  This does not apply to im1dc (one of my most rabid critics) who is sort of our village idiot and is allowed to post whatever he likes strictly for comic relief. -PB)

  15. (I don’t allow ad hominem attacks on our elected leaders. [I did not make one, what were you reading? You went ad hom against me. Moreover, when elected leaders screw-up they need to be be taken to task.]

    Along with convoluted and ridiculous conspiracy theories [I did not offer any conspiracy theory, what were you reading?]

    {snip} I only ask that these be well expressed and free from the usual knee-jerking. [knee-jerk was not evident. But, speaking of which- what is this “broken glass, yellow animal” support you offer? Don’t you like to “think” about your vote? My father and grandfather were dyed-in-the-wool Republicans; bur neither would vote for wrong-headed, arch-conservative Barry Goldwater, or “that actor”- Ronald Reagan. They evaluated and voted for the best candidate.

    And Goldwater figured things out in his maturity,he endorsed a Democratic candidate. When top Arizona Republicans threatened to rename their Goldwater Building to retaliate for this transgression, he retorted “If this is the direction of the party, I hope you do.”]

    This does not apply to im1dc (one of my most rabid critics) who is sort of our village idiot and is allowed to post whatever he likes strictly for comic relief. -PB) [As I recall, that is a soft target.]

  16. Dear PandaBear–

    I’m not responding to your political post. I just wanted to say that I stumbled across your blog the other day, and it made me very happy.

    I’m in my last year of residency and crawling to the home stretch. My journey has been pretty hard, and I’m pretty beaten down. Like you, it seems, I also wish I could burn American medical education and American medicine to the ground and build it back up the “right way”, whatever that is. Our system is way too sick and there is too much money, greed, ego, etc. propping it up to battle it from within, and certainly battling from without using conventional means (such as infantry, tanks, reason, law, or unabashed humanism) seems similarly futile.

    There are plenty of blogs out there written by bitter docs, but, I think many buy what The Man is selling. I have not seen one yet that addresses as well as you have the plight of the powerless trainee fighting his or her way out of the heart of darkness that is resident training in this country. Good for you.

    When I can take a breath, maybe July 1st, I hope to start writing about my own experiences in residency, maybe in a blog like yours. I hope to add my voice to the effort to get people to recognize how medicine is eating its young, and how, as a result, the sentient physicians the public expect will be replaced or run off by technocratic automatons lacking insight and wisdom.

    So, kudos to PandaBear! Bitter residents of the world, unite!

  17. I savor today’s post, PandaBear. Too seldom do I read comments praising Cheney, and he deserves them. It was a stroke of brilliance on Bush’s part to name Cheney his VP, both terms. I look forward to reading many (hopefully many) books about him in the future, about these VP years, as well as his own memoirs.

    The political views you expressed are my own as well, including no interest in hating or vengence and including an appreciation for the government’s wartime wiretapping.

    A big problem for people today, I think, is the lack of interest in reading history. So little is taught in the schools, and what is taught is too often boring, faddish political correctness. A keen interest in studying Western Civilization, by many different authors, would provide our citizens with a solid perspective on every issue facing us, as well as many hours of pure pleasure.

    Again, thank you for today’s post. I also enjoyed (and easily anticipated) the responses, and enjoyed your replies. Actually, thank you for the entire blog. I have a granddaughter (age 15) thinking about medical school.


    (Amen.  I weep at the ignorance of otherwise rational people when it comes to politics, war, and diplomacy.  Take the whole domestic surveillance issue.  The initiative enjoyed bipartisan support in the sense that Representatives and Senators from both parties were briefed in secret and, as even politicians can sometimes set aside naked self-interest, all agreed that it was the right thing to do.  I am perfectly willing to entertain the notion that it may violate the constitution and regretably need to be discontinued but all that is required is for its opponents to bring the matter before a federal court and let them decide.  There is no need to screech and posture accusing our elected representatives of being Devils and Tyrants.  It’s a decision taken in good faith and it can be criticised in good faith. There is absolutely no malice in it and no political or financial gain to be had by anyone involved except perhaps that the electorate may appreciate some vigilance and reward those leaders who attempt to exercise it. -PB)


  18. Dear Dr Bear,

    In reference to insuring the uninsured, you say: “I know too many of them really buy into the notion that they have some kind of inalienable right to my labor.”

    You miss the point, doc. They do have an inalienable right to your labor. You know well that anyone, citizen or not, insured or not, who shows up in your ER will receive the best care you can give him.

    What he doesn’t have is an obligation to have insurance to actually PAY you for your services.

    Universal health care has many forms; one is that everyone MUST have insurance. If they cannot afford a Wii and health insurance, then guess what, they don’t get the Wii. But they do pay you for the treatment you were obligated to give them.


    (I just want to note that unlike most physicians in private practice, Emergency Physicians are contractually obligated to see everyone who comes in the door regardless of ability or intent to pay.  So the patients don’t have a right to my labor, I have agreed by contract to give it to them.  An important distinction.  My internist, for example, does not have an open-door policy at all and you cannot justt walk in and be seen without either having insurance or paying up front (or agreeing to be billed and being dropped if you don’t pay). -PB)

  19. Dear Dr. Bear,
    I respond to the last part of your post arguing that it is the “not really sick” that pay the bills so you can be available for the trauma that really do need you.
    As a republican/free marketer(I gathered from the rest of the post) this seems illogical. Most of those rashes for three weeks that come into the ER are Medicaid or no pay, so in effect you are “losing” money on them….
    And emergent care, rather than continuity, is very expensive and wasteful. My tax dollars into your and the radiologists pocket….Shouldn’t they be seen in their PCP’s office? And taught to not run their life from disaster to disaster, but in a disciplined fashion. That was what I thought my role as a family doc was, to provide APPROPRIATE care. And even some parenting, mentoring, discipline to the chaos prone. And I earned about $45/hour doing that.
    So your cavalier acceptance of”get over it” ER care for what should be Primary Care is, I believe, a big part of THE PROBLEM.
    I won’t discuss politicians….

    (Whoa.  I agree wholeheartedly that many of our patients, many of whom actually have decent insurance, should see their PCP.  The problem is that their PCPs are so swamped that they can’t be seen in a timely manner, not to mention that the standard response to any call to your doctor nowadays seems to be “Go to the ER.”  That’s just the way things are and why the Emergency Department is so crowded, that is, not enough primary care doctors to go around, not enough people who could pay for their own primary care but don’t value your services and prefer to wait for six hours and throw away the bill than pay you up front for a visit, and, of course, the many really poor who have no other choice.

    I repeat, you will see a lot of minor complaints in most Emergency Departments.  That is the way things are. You sound like you’re blaming me for the situation.  Is there anything I said in my post with that you think is untrue?  “Get over it” is directed to Emergency Medicine physicians who feel put upon to deal with minor complaints.

    Hate the game, not the playah.-PB)

  20. Oh, and $45 an hour? Good Lord. I made 30 bucks and hour as a structural engineer working for somebody else and billed roughly 60 bucks an hour when I worked for myself with almost no overhead.

    My God. Tell me you are kidding me.

  21. “I rise in support, therefore, of the minor complaint. Chronic pain? Fibromyalgia? Mild asthma exacerbation? Lips tingled a little after eating shrimp but feeling better now? Upon this sturdy foundation is our specialty built and it is the demand for Emergency Physicians, doctors who can handle everything from a common cold to a traumatic evisceration, that keeps salaries at their current level. Like every other specialty, Emergency Medicine is a volume business and the volume has to come from somewhere.”

    Cut and paste can be tacky. BUT, here’s YOUR words. If that is not an endorsement of mercenary medicine(read Overtreated, Brownlee) and exploitation, it is at least an acceptance of it. And the cynical acceptance of injustice is a tyranny in itself.
    Nope, we got a messed up medical system, and doctor’s entrenched self serving has gotten us pretty far down this road.
    Your playah analogy: yeah, I hate the player that cheats and gets away with it because the ref doesn’t see or care. I guess I’m still in the Pollyanna phase of expecting some fairness.
    Nope, I love THE GAME….it can embody ideals and goals…It’s us playahs who fall short.


    (Again, whoa Nelly.  I don’t have any control over the system, none at all.  Absolutely zero.  But as I would like to get paid for my time and trouble I have no choice but to work within the system.  Currently, for reasons about which we agree, the system is set up for the proceduralist over the cognitive thinker and the acute care over the long-term care.  That’s just the way it is and if you are suggesting that I eschew the big salary to open up a medicaid clinic where I spend hours with every patient at the expense of total billing, well, I guess I will have to accept the Mercenary label.  My self-immolation won’t change a thing. 

    In other words, I accept the system as it is and, as a corollary, don’t give two figs for most of the reform proposals being floated by either party as they will do nothing to address the strucutral problems of the system.

    Also, the implication that I am somehow cheating the system is unwarranted.  We bill what we bill and the group that runs our Emergency Department is extremely scrupulous about properly coding every encounter.   -PB)

  22. By the way, love your blog. You can write circles around me and if you ever want to guest author something about primary care and how it is structured I would be happy to post it.

  23. So, Dr. Bear, are you completely against EMTALA? Is there a soultion you have in mind that would counter the negatives associated with EMTALA?


    (Oh no.  I’m all for it in the sense that it guarantees that Emergency Medicine will be a high-demand specialty for the forseeable future….but you know, I’d rather work in a system that was rational, even for less pay, if it was done in the cotext of decreasing the bite of the nanny-state which ain’t gonna happen on this planet in this century.  Unfortunately I am a prisoner of the system as I have loans, lost assets, and lost income like a big dog and I have to make money or this whole adventure will have been so not worth it. -PB)

  24. “So I haven’t exactly caught Ron Paul fever. I like the guy, of couse, and he would be a perfectly acceptable candidate despite his opposition to the war in Iraq”

    Oh, man, that’s one of the best reasons to vote for him. And I have only the vaguest idea about the Daily Kos (I think they hate Ron Paul), but Cheney gives me the chills.

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