Random Notes from a Febrile Mind

(I am sick, the flu or somethin’ and I lack the energy to sustain any coherent ideas. Fortunately I am also on vacation which is great! Trust me, only the experience of residency training can make you happy to be sick while on vacation. Here are some completely random thoughts, some of them completely non-medical. Indulge me, Okay? -PB)

You Folks Have Got it All Wrong

I have received quite a few comments, both public and to my private email address, stating that my recent stories of asinine patients with trivial complaints have driven the last nail in the coffin of the reader’s once burning desire to go into Emergency Medicine. I’m sorry. That’s not my intention. And you have it all wrong. I can only speak for the non-surgical specialties but in these, there is not one single field into which you may match where you will not spend a good deal of your time wading through a lot of bullshit. Medicine, for most doctors, is mostly little potatoes and not the epicurean baked potato buffet that many of you think it to be. Give me any specialty and I can name for you the top ten or twelve presentations that will fill ninety percent or more of your day. And every specialty has to deal with the patients for whom nothing can be done, who really have no need to see a doctor, and have all kinds of emotional problems but very few medical ones although I suppose the more hyper-specialized you become, if you are a true consultant and not just a physician extender for primary care, a lot of these will be weeded out for you.

And let’s face it kids, despite what is shows on the television, medicine is not sexy. Unless you are a pediatrician, the majority of your patients are going to be elderly and pushing their expiration date. Most don’t have a compelling story nor are they flaming beacons of some social cause or another. For the most part they are plain, ordinary folks with complicated but entirely believable medical problems which will defeat both of you and they are not headed for any other redemption but that of our Father in Heaven.

This doesn’t mean that you aren’t doing important, difficult work, just that most of your patients, even the sick ones, can become routine…unless you take to heart the following advice:

There may be boring diseases but there are no boring patients. I have met, briefly of course, counting family, maybe fifty-thousand people in the last seven years and I still cannot predict how anyone is going to act or how any particular patient is going to behave. The secret to enjoying a career in medicine is to be interested in people. You don’t have to like them, you can hold them in contempt or love ’em like a saint, but if you have no interest in mankind you will grow tired of the routine quickly.

Now, as far as specialties go, you will see the greatest range of people with the greatest variety of medical problems in Emergency Medicine. And we do occasionally directly, no-doubt-in-our-minds, save a life or perform some heroic deed of medical prowess. Family medicine residents, for example, probably save a lot of lives the slow, old-fashioned way but intubating and resuscitating a decompensating crack addict? No way. That’s our job. And if he keeps smoking crack? All the better. More practice for us. A real win-win situation.

Code Pink

A couple of weeks ago I had as a patient an elderly gentleman who, seeing the Marine Corps pin on my white coat, disclosed that he had been a Navy Corpsman in the Pacific during World War Two and had taken part in the landing on Iwo Jima. It was a great honor for me to be his doctor that night because our Corpsman (what the Army calls “medics”) are legendary for their courage and this guy probably saved a few Marine’s lives in his time. Which sort of reminded me of “Code Pink,” the Berkeley City Council, and their completely idiotic exercise in civic irresponsibility exemplified by their attack on the United States Marine Corp’s recruiting efforts in their city.

First of all, almost everybody loves the Marines and you’d have to be some kind of brainless moron to think that your dislike is shared by more than a handful of similar brainless lunatics. Even in Berkeley, the most left-wing city in the United States, a place that makes the North Koreans say, “Dang, them folks are really left-wing,” the response to this outrage has not been nearly the happiness and light expected by the tired old hags protesting the lack of masculinity of their own sons. Sorry ladies, not every mother wants her sons to major in expressive dance or learn peaceful conflict resolution from some dope-smoking hippy. Normal mothers, while justifiably fearful of the risks of war to their sons, would prefer them to carry their shields into battle like men and not throw them down in fright at the first sign of trouble.

That’s kind of the secret of Code Pink. It’s got nothing really to do with this war or any other war in particular. It’s a protest against the kind of men they wish their sons had been masquerading as civic virtue and perpetuated by some of the most close-minded and frankly ignorant people who have ever been taken seriously by anybody.  When asked, for example, if the United States should have stayed out of World War Two after the Japanese bombed Pearl Harbor, one of the Code Pink protesters replied, “Well, what were we doing in Hawaii anyway?” If this doesn’t demonstrate a profound ignorance, a truly criminal lack of both intelligence and historical perspective..well. I don’t know what else can be said. The fact that a city council, ostensibly composed of the best and ablest citizens, would give these ladies an ounce of credibility just shows that they, too, are a bunch of gutless pussies of whom their city should be ashamed. And stupid too, because the Marine Corps is not an exclusive club for conservatives. There are plenty of prominent liberals in private life and government who count their service as Marines, not to mention other branches of the military, as one of the most important aspects of their lives. You can be as anti-war as you want to be (although why being anti-war is the default liberal position is not clear except in the context of the virulent Bush Derangement Syndrome with which many on the left are afflicted) but I’m sure quite a few liberal former Marines take mighty exception to being called “baby-killers” and “brain-washed murderers.”

The Marine Corps just ain’t like that. Not only do we not train to kill babies (that would be the other side) but the Corps has precious little interest in its Marine’s political beliefs, voting habits, or even opinions on this war or any other (except in the context of how best to kill the enemy, of course). What the left calls brainwashing is just self-discipline, and primarily the self-discipline to know when to keep your fucking gob-hole shut and when to suck it up for the good of your fellow Marines. We do not have to be unique fucking snowflakes all the time. Occasionally we can think about others which is what Marines do instinctively but professional protesters against everything do not.

As Al Qaeda desperately try to extricate themselves from their own little quagmire in Iraq, as the war tuns in ours and the Iraqi people’s favor after a difficult counterinsurgency campaign that has been little understood by the know-nothings in the media and academia (who know about as much about military operations as I know about the Lesbian subtext of Elizabethan drama), as various Democrats tentatively construct strategies to declare victory after promising defeat, it would be well for everybody, liberal or not, to get on the right side of this thing. Our nation may not be perfect but we’re not shooting women in the head in soccer stadiums. The idea that an uber feminist group like Code Pink would act in cahoots with a terror movement intent on re-implementing the Islamic dark ages when women were property and could be stoned for looking cross-ways at a man boggles the mind…but is just another normal doublethink moment for the lunatic fringes.

The Well Will Run Dry

To hear the various supporters of universal access, single payer, or whatever is the current euphemism for socialized medicine describe it, proclaiming universal coverage is going to solve not only the cost problems of American medicine but also those of access. It’s as if the Obamas and Clintons of the world believe that there exists vast underground reservoirs of medical care which only have to be tapped to provide Americans with all the medical care they can eat. But, as anybody who has waited in our department or cannot get a timely appointment to see his doctor can tell you, we are operating pretty much at capacity right now and not only is there no reserve to tap but medical care is not a tappable commodity anyway, at least not like that. The only extra capacity will come from eliminating waste and unnecessary uses of medical services, something which will not happen when medical care is free because, unless there is some direct cost to the consumer, there is no incentive not to go to the doctor for every little thing.

In fact, everything about “Single Payer” is going to make medical care an even scarcer commodity. Just an increase in demand, that is, giving the Holy 47-million-uninsured (PBUTHN)Â sudden and equal access with no possibility of increasing the supply of medical care, by itself will lead to a relative scarcity. That’s just simple math. Additionally, after an initial bonanza of insurance money to mollify the various short-sighted medical societies pushing single payer (including, unfortunately, my own) the pressure on reimbursements in the absence of any competition will be down, and down, and further down until at some point there will be so little incentive to see more patients for the government dime that we will stop working so hard and adopt a more European approach to a full waiting room or a long list of patients needing elective surgery. Try getting a doctor in the VA to see patients in the late afternoon for a preview. I mean, if we’re going to be government employees (de facto or otherwise) we may as well get all of the perqs including all the usual holidays, coffee breaks, lunch breaks, and the sure knowledge that we can never be fired. Remember, doctors in the German Federal Republic work around forty hours a week. The baby-boomer armies who will shortly pillage and burn their way down our medical Danube are going to need a lot more hours of our time than that to collect their booty of knees, hips, colonoscopies, and other plunder.

The correct play is to make going to the doctor cost something for everyone (no matter the income level) to discourage frivolous use of services, enact national tort reform to begin to give physicians some cover behind which to start to exercise more common sense, to frankly eliminate most government involvement in primary care letting the market decide how much patients will pay for a doctor, and if we must provide free health care, limit it to the extremely poor and to government backed major medical insurance for which all but, again, the very poorest should contribute something. We might also start asking the elderly who have assets to kick in a little more for their own medical costs. I wouldn’t want to bankrupt anybody but would it kill many of the elderly if Medicare was means tested just a little? The idea is to set the stage for a little more patient and family involvement in real medical decision making, not the pretend decision making we have today where the answer is usually, “Do everything that someone else’s money can buy.”

Integral to this would be to start implementing EMTALA like it was intended, that is, to offer only a free screening exam and if no emergency medical condition is discovered, to allow the hospital the option of sending the patient home to follow up with his own doctor for whom they can pay if they want to. This would remove the “out” that people currently have to avoid taking money out of their tatoo budget to pay their minor, primary care-type medical bills. I’d also get rid of the Childrens Hospital (I)nrichement Program, also know as “CHIP.” Almost a complete waste of money as, again, most children just need a little low-cost primary care. I don’t think it would bankrupt us to pay for major medical expenses of children because, and hold onto your hats, most children, even the children of the Holy Underserved, are fairly healthy. Just pay for their necessary major medical care directly out of tax money and stop trying to comprehensively insure a population that doesn’t really need it.

The idea is to decrease the federal obligation, money that we don’t have and the borrowing of which is going to bankrupt our nation. Better to have a low tax economy where people are free to spend their own money how they like. If they decide to get that bitchin’ nose ring instead of their antibiotics, well, that’s just freedom, baby!

24 thoughts on “Random Notes from a Febrile Mind

  1. I love hearing premeds and college kids quote the 47 million or so uninsured.

    Heres an interesting vid about the holy 47 million

    Yep can’t be bothered to by health insurance when I could spend that money on Iphones and other stuff.

    We need to work out a plan to help those who want insurance/health care and can not afford it. Less on my priority list is giving people like the ones in the vid free health care so they can get tickets to the FISH concert.

  2. “The idea that an uber feminist group like Code Pink would act in cahoots with a terror movement…”

    Look, I’m an active-duty Army officer, and I completely agree with a lot of what you’re saying, especially about how offensive and ridiculous the situation in Berkeley is. But it’s still silly to say that the left, including Code Pink, has somehow allied itself with the terrorists. Sure, there are a few nutcases out there who think we deserved to have 9/11 happen to us (although they’re not all liberals — witness the Christian conservatives who blame terrorism on God’s anger at gays and feminists).

    (Reasonable people may disagree.  Let’s just say that groups like Code Pink are “useful idiots” for the islamofascists.-PB)

    But the vast majority of leftists who are opposed to the war (I’m one of them) oppose it not because we love terrorists, but because we think that the invasion of Iraq never had anything to do with fighting terrorism (Afghanistan is a different story) and that our present involvement there is unlikely to provide any benefits to the U.S. that outweigh its cost in lives and resources. Because, right now, this war is breaking the Army. People are getting out, the quality of newly enlisted soldiers is dropping, and talented people who love the Army are just getting worn down by the constant deployments — not to mention all the soldiers killed or disabled. If a real, serious threat to our national security developed somewhere else in the world, we would not have the ground troops to fight it because the Army is already stretched so thin. I believe in having a strong Army and a strong national defense capabiity, and this war is making it unnecessarily difficult to achieve either of those goals. Holding these views doesn’t mean I’m “in cahoots” with the terrorists. You want to find someone who’s in cahoots with the terrorists? Look at the crazy evangelical Christian conservatives who want to impose the equivalent of sharia law on the rest of us.

    (There is no evangelical equivalent of Sharia law.  Not even close.  Sorry.  Terrorism and Sharia Law (which is terrorism against women) is the mainstream or at least a very popular outlet of modern Islam. -PB)

  3. The doctors in Germany also went on strike a few years ago because they dont work 40 hours. They are paid for 40 hours, and they were in fact working much more.

    Get better Panda!

  4. 1. I hope you feel better, and are following the number one rule for vacationing, sick or well: always have a tropical drink in your hand.
    2. I’m a little nervous about responding to your “Code Pink” section, but here goes: you note that “normal” mothers would rather see their sons carry their shields into battle and not throw them down in fright. There is another aspect to this. My father also fought in WWII. He was in the Pacific, in the Navy. When his destroyer was sunk, it was a Marine, and not the Red Cross, who provided him with some clothing and access to paper and a stamp. He did what he had to do because everyone expected it of him and he was a man. He also came out of the Navy weighing 100 pounds (6’1″), unable to sleep or eat. Battle fatigue was not recognized as anything other than a sign of weakness. So, one hospitalization and several traumatized relatives later, he died of a heart attack at an early age. I am convinced that it was only his Irish sense of humor that saved us all from total implosion. And you can be absolutely certain that the last thing I would ever say to my son is some variation on “Come home with your shield, or on it”. I don’t have an aversion to the military as such – I am proud of my daddy for doing what he had to do. But it destroyed him and they are not getting my son. If that makes me not a normal mother, it is very much because of what I saw happen to my father as a result of his military service. My father was and my son is a good man, and it has nothing to do with their ability to go to war. I hope you can understand that if a mother objects to giving up a child to the military, she is not automatically a Code Pink loonytune.

    (I repeat, Code Pink are a bunch of looney tunes.  You can be pro-military, anti-miltary, Republican, Democrat, liberal, or conservative and recognize that. -PB)

  5. Amazing, Panda, even when ill, you speak the truth.

    Had a patient the other day with a wart on his finger that he wanted me to take off. And yes, he had no insurance. But he had some very intricate tattoos located throughout his body. Bragged about them being pricey tattoos, too. Was shocked to find out that I wanted some small amount of money up front for wart removal and left my office in a huff.

    Get patients all the time with no major illness, but because they have the “card”, they get to see the ‘specialist’. Saw a 27 y/o male with constipation and wants a colonoscopy. No other symptoms except probably chronic dehydration from drinking 10 cups of coffee a day. The colon needs at least some fluid to squeeze out that brick.

    Maybe… a catastrophic-only health plan to all. Free preventive care for the children, elderly, and disabled. All the rest, have some form of co-payments stratified according to income. And yes, the elderly who are well off should stop getting wholly subsidized with Medicare. My own parents, who are very well off, still use Medicare and their argument is that all their neighbors do it, too (they live in one of the top ten richest counties in the country).

  6. PB,
    You mention tort reform as one of many components in your proposed health care reform. Do you mean some kind of lessening of the physician’s responsibility in a malpractice suit? Do you anticipate this equating to larger compensation (relatively) for the doctor? As much as I despise the litigious “it’s my money if I can wrest it from your cold dead hands” attitude so prevalent today, will tort reform lead to lower costs of medical care? Or, will it just lead to happier, and perhaps more engaged, physicians?

  7. The problem is that the majority of Americans do not want to “do their share” as it were, whether that’s pay for health care, or much of anything else. They want to do as little as possible.

    When one suggests that they pay for at least a part of their own care, they see the doctor who has (admittedly) a higher income than they do, but works many hours more than they have and has given up so much of their lives for training. To many of my patients that counts for nothing. they demand so much, and then complain when it’s not free.

  8. Speaking as a socially liberal and anti-war kind of guy myself (though my anti-war stance has little to do with my socially liberal stance and I agree that your personal views on war have little to do with the rest of your political philosophy), I have way more in common, ideologically, with Panda Bear than with Code Pink. It’s unfortunate that they are getting the press they are, since this only reflects poorly on liberals in general.

    It’s similar to the routine ‘shock pieces’ we see about the KKK and their extreme conservatism. Funny enough, the more mainstream conservatives distance themselves well from the KKK while many mainstream liberals will make excuses for Code Pink. Though… Code Pink doesn’t want to lynch anyone. At least I hope not.

    Reasonable people may disagree indeed. There are many who claim that the indiscriminate use of the military in multiple theaters is in fact playing into the hands of the islamofascists. There are others who claim the islamofascists are not nearly as large of a threat as they are made out to be. But these points of debate aren’t what you wrote about in your post, and while I think they’re important to think about I also think we can all agree that Code Pink is a misguided group of extremists at best.

    (Let me just comment on the theory that killing terrorists in Iraq, Afghanistan, and around the world is “playing into the hands of the islamofascists.”  That’s just a piece of muslim agit-prop disguised as “conventional wisdom” and part of a broader appeasment mentality in much of the West.  It’s the “Let’s not make ’em mad or they’ll get mad” approach to warfare which makes no sense. essentially letting the “Arab Street” dictate military policy.  Now, in the last five years we have invaded two moslem countries, set up shop, slaughtered tens of thousands of terrorists, and we haven’t heard much of anything from the Arab street except the usual Anti-Americanism and Anti-semitism.  Al Qaeda is so short of recruits in Iraq that they are using mentally retarded kids as suicide bombers and eyeing their exit stategy before they are completely wiped out, something that has been increasingly documented but not something you’d know if you get your news from NPR or the other usual suspects who wring their hands and worry about making ’em mad.  To imply that killing the enemy and disrupting his logistics to the extent that he can’t conduct operations is “playing into their hands” is ridiculous.  What Al Qaeda and other terrorist groups really want is for us to adopt a European approach to them, that is, to talk talk talk talk but never actually do anything.  That’s playing into their hands.  The only advantage the islamofascists have is the fear and indecision of much of the West and, as it’s a very important weapon for them they’re going to use it. 

    Come on now.  Part of warfare is knowing what your enemy has and how he intends to use it.  The typical islamofascist propaganda and dire warnings that we don’t want to make ’em mad are just one of their tactics which, if you can recognize it as bullshit takes an otherwise effective weapon away from them.  The correct response to the threat from some Dark Age jihadist that we are creating terrorists by killing them is to observe that we have plenty of bullets and nothing better to do.  The very fact that we are willing to hunt them down on the ground probably came as quite a shock to them anyways, as they had been promised that Americans couldn’t fight like that.   -PB)

    I was wondering when I’d see you address this group in your blog, to be honest. If they aren’t ‘low-hanging fruit’ then no liberals are.

    Thanks for the great entry and congrats on your 300,000th visit!

  9. You’re views on health insurance are fall under the ideology of ‘moral hazard’. Numerous studies have shown that pursuing this policy does not yeield good outcomes. A better policy, I believe, for preventing wasting of resources on the loonies with fibromyalgia and other non-problems would be to institute a true triage system like you suggest for dealing with EMTALA.

  10. In case anyone is interested, the video the first commenter “D” posted in his comment is part of a series (currently 4, one coming) that can be found here: http://www.freemarketcure.com. All good food for thought. I think you’ll like them Panda, if you haven’t already seen them.

  11. Brian, just what exactly does one study to determine what this policy does or does not yield when it has not in fact been tried?

    If by a bad outcome you mean that people will choose to spend money on some luxury instead of health care, and thus may not have the funds to lay out when necessary, then you may well be right. I see no reason to reward people for their bad habits. I’m not talking about the truly poor who genuinely cannot afford what they need. I’m talking about people like my kid’s school aide who bought herself a Lincoln Navigator but who can’t afford routine repairs on the car she uses to commute.

    Or, perhaps, the example with the tattoos Grumpy Old Scalpel mentioned.

    But even the very poor in the US can usually afford a $5 or $10 copay. They spend at least that much on cigarettes. If that makes them choose not to seek out health care — then that’s their decision not to seek out this necessity of life. Just like you go hungry if you don’t buy food.

    On the other hand, the problems PB discusses about single payer aren’t theoretical. They are actual problems that actually exist wherever a plan like single payer is implemented. Do you really want to live in a country where the doctors go on strike?

    Too bad we now have an entire generation well-trained to expect free health care. I have excellent health insurance, but I get nothing for free. The premiums come out of my paycheck, and considering my family’s medical needs I spend thousands a year in copayments alone. I see no reason to give away the store to everyone else.

  12. Well, we all gonna have a brand new crop o’ pigs we gwine let mosey up to the trough. How we gwine feed the extrys? Well, we gwine make the walls of the trough higher so’s it harder for them to get their snouts in and so less of the feed slops out and goes to waste on the ground. Not only that, we gwine make them lazy overpaid farm hands work longer and harder to keep that there trough filled. Them there shiftless no-accounts are already getting 3 squares and a bunk. If that’s enough for the stableboys, it should right suffice for them.

  13. As far as malpractice reform goes, predictability would go a long way. Being sued is fucking miserable. You absolutely cannot comment on it until you’ve gone through it. You’ll feel like you’ve had a good day and then realize you’ve got a goddamn lawsuit hanging over your head — for a year. The problem is that even if the suit is complete garbage, there’s no guarantee that a) a jury will understand medicine well enough to know that and b) sympathy for the plaintiff won’t result in them feeling like it’s better to stick the bill to the insurance company.

    Honestly, I wouldn’t care if malpractice premiums stayed exactly the same (although presumably they should go down if garbage lawsuits are removed). All I want is to know that I don’t have to practice “defensive medicine” because I’ll get sued for 60 million dollars if my 99.9% certainty of heart attack happens to fall into a 1 in a million case of aortic dissection. Covering your ass from zebras is the source of much of the massive growth in health care spending and it DOESN’T HAPPEN in other countries because their legal systems don’t expect you to CT every patient to rule out a .01% chance!

    It’s win-win for patients and doctors — but of course the third party here that loses (cough cough) will make sure it never happens.

  14. “my recent stories of asinine patients with trivial complaints have driven the last nail in the coffin of the reader’s once burning desire to go into Emergency Medicine. I’m sorry. That’s not my intention. And you have it all wrong.”

    Well, I posted that on your last entry, so I’ll just clear up what I meant. I have a few different prospective interests, of which I can easily think of commonly recurring chief complaints that I’ll be dealing with regularly, as well as some minor complaints. That’s not what bothers me. I also have several years of experience in EMS dealing with extremely minor complaints that made their way to the ED, but it wasn’t even that that put me off from EM. I certainly had no glorious concept of EM as being saving one GSW pt after the next, followed by a massive MI and then a mass-casualty incident involving a bus full of school children.

    It just seems that EM has the highest concentration of people who want to bullsh*t you and manipulate you into what they want – drugs, an excuse from work, a free ultrasound, whatever. I don’t mind minor complaints, but I really wish they would just be sincere ones. It’s also the fact that you KNOW you’re throwing money down the tubes for someone that is, at best, not contributing anything to society, and it’s because they don’t want to, not because they are incapable of doing so.

  15. doctorjay:

    First, there’s a typo in your website link. It ain’t gonna work.

    Second, no one wants to make health care so expensive that the genuinely poor can’t reach it. If you really think someone here is saying that, you don’t read very carefully.

  16. Panda – I love your site. You say exactly what I think with such pungency. Marines and all.

    Re: useless complaints: that’s the great thing about surgery. The ER weeds out most of the chronic/supratentorial things for us. Only a fraction of our patients truly have no anatomical pathology. They exist, of course, but thanks to you, in small numbers.

  17. “A better policy, I believe, for preventing wasting of resources on the loonies with fibromyalgia and other non-problems…”

    Come on, Brian, these are real people with real problems. Are you saying you just don’t know how to treat these people?

  18. Chris, I don’t care about “justice” and making sure that people don’t game the system for a few bucks worth of a copay. I care about making sure people get the care they need, bettering public health on the grand scale (both for humanitarian and economic reasons) and decreasing costs on the national scale. Simply put, moral hazard policies do not work in terms of providing acceptable outcomes or cost-savings. Remember, if someone refuses to take care of their diabetes by visiting a pcp and keeping it under control, eventually they’re going to need a helluva lot more medical care at a pretty big pricetag.

    Randall, no I’m saying that they don’t need to be treated. Diagnosing someone with fibromyalgia is the worst thing you can do for them: it clinicizes their problems and brings them into a medical system that cannot hope to offer them any relief. Not to mention that they drain a great deal of resources from other patients who actually stand to benefit from medical intervention.

  19. “As Al Qaeda desperately try to extricate themselves from their own little quagmire in Iraq…”

    Sources? (I don’t doubt you – I just want substantive ammunition to throw at people.)

    And I agree with your rage at the “wimp attitude” of some people. G.W. Bush may be a fucking awful US President in the eyes of many people, but in very many ways he makes a good wartime President.

    The British found out the hard way in 1915 that in order to put men into a location where the enemy was armed with automatic weapons, the entire area had to be transformed into a moonscape with artillery if your people were not going to take prohibitive losses. The fact that the US military is taking losses that some of its fellow citizens regard as prohibitive (but would be no more than a week’s fighting in some places on the old Western Front) is an indication that it is prepared to spend its soldiers’ lives rather than regularly and indiscriminately transform civilian areas into moonscape. Babykillers my fucking arse. (An Australian soldier was killed in Afghanistan not long ago because IIRC although he and his mates could see the terrorists moving into position, the bastards were surrounded by civilians, whom the Aussies didn’t dare risk hitting. The day we start forming battalions of Down’s Syndrome kids with rifles? THAT’S the day we become “morally equivalent to the terrorists”.)

  20. Brian: So you say, but to continue as we are or under single-payer is unsustainable, and in the long run will be (in many ways already is) a lot more destructive to the medical profession than the alternatives.

    The alternatives used to work. That they no longer do (if they no longer do) is because sufficiently large numbers of people have been conditioned to expect to be taken care of, not that they should take care of themselves. I don’t doubt that many of your type II diabetes patients don’t really need to see you to keep it under control. They need to control themselves. How many such patients who are able to do so, do as they’re told in terms of diet and exercise? How much better off would they be if they did?

    And how on earth is it a “moral hazard” to expect that people should take some responsibility for themselves in ways well within their means? Neither you nor I are responsible for choices other people make. If we collectively try to take responsibility, we will bankrupt ourselves as a nation. We are bankrupting ourselves. It cannot go on.

    PB writes from the perspective of EM so EMTALA looms large, but when you look at the broad picture you see it’s only a small part of the problem. It needs to be fixed, but it’s not even close to a full solution.

    (EMTALA effects every hospital-based specialty because if the non-paying patient needs to be admitted the various specialties with admitting privileges have to give free care. -PB)

  21. Brian wrote, “Diagnosing someone with fibromyalgia is the worst thing you can do for them: it clinicizes their problems and brings them into a medical system that cannot hope to offer them any relief. Not to mention that they drain a great deal of resources from other patients who actually stand to benefit from medical intervention.”

    Many people with FMS wonder what the heck is going on and when they finally get a label, are actually relieved…and now know whch support group to join. The failure of the medical system is just that, a failure. And FMS patients can sometimes benefit from medical intervention except when they find themselves facing someone like you, perhaps.

    Functional Somatic Syndromes also include Gulf War syndrome. Would you treat those cases the same as someone with FMS?

  22. Panda,

    I had a really long and (at least, in my own vain opinion) good response to your comment about making the terrorists mad. I think it got swallowed by your spam filter. Too bad, as I don’t have the skill to recreate it from scratch.

    (I’ll see if I can find it in my email moderation cache. -PB)

    I would consider that captcha plugin that was mentioned some time back. Might help avoid these quite frustrating situations.

    And maybe I need to pick a new handle. Really, I know Doctor J was a legend, and my name starts with a J, but apparently every other doctor whose name also starts with a J thinks the exact same way.

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