(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.
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.Â 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!