Quick Learner

So I had a drug seeker come in the other day with her usual back pain.  Lately I have been very stingy with narcotics and after refusing to give her a shot of anything stronger than Toradol I explained that I only give narcotics for patients with fractures or obvious acute injuries and never to patients with chronic pain (which is not strictly true but I thought it would be impolite to point out in front of her family that my records showed six visits in the last two weeks to our other Emergency Departments around town).

In my discharge instructions I cautioned her to return for numbness, weakness, urinary retention, or urinary incontinence (all things that can be caused by spinal cord injury) and wouldn’t you know the next day she showed up with a normal gait, normal neurological exam, normal deep tendon reflexes but having ostentatiously wet herself, something she mentioned to me as she stumped past on the way to her room.

Nice try.

Apparently the internet is loaded with sites where drug-seekers can learn what to say and how to present themselves to Emergency Physicians to get drugs.  I’m less than impressed by a patient who endorses twenty-out-of-ten pain in the right upper quadrant brought about by eating fatty foods who I have to shake vigorously to awaken but some of them are quite good.  I’ve been burned a few times, suckered into giving Dilaudid to patients who I later discovered to be frequent fliers.  The first warning sign is usually the inability of a normal dose of Dilaudid…essentially legal, high-grade heroin…to “touch the pain.”

The Holy Grail for the seeker is, of course, being admitted for intractable pain and being put on a “pump,” or Patient Controlled Analgesia (PCA) which is like having your narcotics on tap.  Still, suckering the doctor into giving you a few hits of Dilaudid before the unamused charge nurse hands him a stack of papers detailing your last twenty visits is a major victory as is scoring a ‘scrip for Lortab.

Oh, and just a tip: If you are young, otherwise healthy, and look stoned (because you are stoned) I’m not going to give you anything but some life advice so don’t bother coming in.  Your back may or may not hurt but many people older than you with real skin in the game have survived back pain with nothing more than Motrin.

Just an aside, I write prescriptions for Motrin because it only takes one mouse click on our Electronic Medical Record system but I always hand-write on the printed prescription, “Over the Counter, Not for Prescription.”  I’m really busy so a minute saved here and there can add up to real time over the length of a shift.   I don’t care if you have Medicaid and they will pay for it.  It’s not asking a lot for you to throw down a couple of bucks for your own medical care.

I still get frantic calls from patients saying that my prescription says “600 mg” of Motrin and all they sell are 200 mg tablets.  I weep for this generation.  Have Americans always been this stupid or is this something recent?  It’s probably a recent thing.  My older patients may or may not have a college education or advanced degrees but most of them seem to have some basic common sense.

We are definitely getting less intelligent.  Apparently being a moron is not only an accepted lifestyle choice but, given the growing allure of the welfare state, it is now also a desirable survival characteristic and one that is being aggressively selected for.

Patient of the Week

“My Doctor told me to come in to be admitted for back pain.”

“I have no doubt your back hurts but as you are clearly without neurological deficits, appear comfortable, have no fever, and a negative urinalysis there is no indication to admit.  What kind of doctor is he?

“A chiropractor.”

“We have an automatic door in the department so it you move quickly it won’t hit you on the ass on your way out.”

The Crying Game

Remember that movie where, after a couple of hours it is finally revealed that the chick is a dude?  That’s kind of like President Obama.  All of his breathless supporters thought he was a beautiful, sensitive, caring girl but now 200 days into his presidency he has shown everybody his penis and, although they still want to like him, it’s hard now because the chick’s a dude, man.  Sort of changes everything.  I mean, she still sounds the same, looks the same, is wearing the same clothes but she’s a guy…and all but his most ardent followers must be squirming in their seats to think they were ever attracted.

Sure, the die-hard zealots, those who have in the dead of night surreptitiously scraped off their “Dissent is the Highest Form of Patriotism” bumper stickers still think he’s good-looking even if he has a twig and berries but the majority of Americans, those who care I mean, are catching on that the Sun God, Ra-Obama, is something of a petty dictator along the lines of Mussolini.   That and he is completely out of his element, not very smart, and well along in completely screwing up the one thing he was mistakenly elected to fix.  A silver tongue/teleprompter and charm are not a substitute for basic intelligence and some friggin’ common sense, even in the insanity that passes for American political culture.

I’m Back

As many of you know I recently finished my residency training and am now working as a real live Emergency Medicine Attending Physician, completely autonomous and completely responsible for every decision I make.  It has been an easy transition so far because, and you may read this as a defense of the need for residency training, my program trained me well to handle the full range of medical emergencies that we commonly (and uncommonly) encounter.   More importantly however, my program trained me to be comfortable with the not-so-emergent patients; the ones with a blurry constellation of mild complaints and extremely vague exam findings.  The truth is that there is a lot of general medicine in Emergency Medicine and as one of the most common presenting complaint appears to be, “I couldn’t get a quick appointment with my own doctor so I decided to come here,”  I am beginning to understand that my job is not to work up everybody all the time for everything.  While I still reflexively admit the usual patients (chest pain, elderly with unexplainable pain) I’m sending a lot of people home with instructions to follow up with their own doctor…even going so far as to call the doctor in question for patients I think are unreliable.

I mention this because I sent a patient home with vague abdominal pain who came back the next day and was diagnosed with appendicitis by one of my colleagues.   You might say I missed the diagnosis but I respectfully submit that, as the patient was given clear discharge instructions to return if not better (which he did) we can put that one in the win column.  It’s either that or we CT scan every patient with no fever, a normal white count, a benign abdominal exam and absolutely none of the classic findings for appendicitis except a very mild, intermittent pain in the lower abdomen that didn’t even localize to the right lower quadrant.

I’m also beginning to appreciate the utility of the “Likelihood Ratio” and how it applies to Emergency Medicine.  Our most excellent Program Director drummed statistics into us and we naturally resisted manfully but it is good to now have some theoretical basis upon which to justify not ordering labs or studies that will not effect treatment or disposition decisions.   I still reflexively order Basic Chemistry Panels and Complete Blood Counts but one day I’m going to get the nerve not to do it.  I wonder how much money we waste checking these things on people who look healthy?

Just file it under not wanting to know everything about every patient when usually it is enough to address the chief complaint and be done with it.  Which brings me to one of my biggest pet peeves, that is, the ordering of imaging studies and lab work in triage.  Sure, sometimes this practice speeds up disposition but not every patient, for example, with abdominal pain needs an Acute Abdominal Series; a set of four xrays at my hospital.  With a few exceptions, the Acute Abdominal Series should be reserved for, well, patients with an Acute or “Surgical” abdomen which I assure you most of my patients do not have.  Vague abdominal pain certainly does not qualify and the Acute Abdominal Series is completely useless in either ruling in or ruling out anything useful in the majority of patients for which it is automatically ordered.

If I suspect something is going on I’ll get a CT scan.

Not only is the routine ordering of unnecessary imaging wasteful but once we get the study we are now on the hook for every finding on it, even those that are incidental.  If I miss a small pulmonary nodule on an unnecessary chest film that later turns out to have been lung cancer I own it and the ensuing lawsuit.  Better not to know…especially if the guy came in for a sore throat and no other respiratory complaints and with a completely normal lung exam.

The triage clerk is killing me.

Poker and Other Things

Michael Jackson is Dead and I Don’t Care

Michael Jackson is dead and, God forgive me, I don’t care. I wasn’t a fan and I didn’t like his music. Sure, I listened to it; it would have been impossible not to but I never bought an album, stopped turning the dial at the sound of his falsetto voice, or really followed his career except that it was part of the cultural noise of our age. I don’t worship celebrities and entertainers either and am completely indifferent to their lives. Oblivious, actually. I’ve been listening to Pink Floyd for thirty years and I can’t name any band member, differentiate who among them is living or dead, or tell you anything about any of them. Don’t know, Don’t care. It’s not important.

Of course I watched Michael Jackson’s opulent funereal. How could I not? I couldn’t tear myself away from this sad commentary on our silly and insipid age where a mincing creep, a pedophile, and a middle-aged man who spent the treasure of a small nation to satisfy his bizarre urges is buried like a pharaoh while better and braver men who sweat and bleed every day are rewarded with nothing more than a flag-draped coffin and the barely concealed derision of the perpetually chattering classes.

What a freak show it was. A parade of Jacksons you never heard of and flocks of B-list celebrities come to preen and feed on entertainment carrion under a grisly sun. I think it’s weird and freakish how the black community has embraced embarrassments like Al Sharpton who delivered the most embarrassing eulogy of the day. What a low-life, likewise flapped in from lonely media desolation to feast on the dead body that seemed hardly enough to feed a couple of washed up singers let alone the small country’s worth of celebrants descended on Los Angeles. Was it some miracle, feeding the multitudes I mean?

The ongoing news coverage was disgusting. North Korea will be lobbing nukes at us pretty soon, the economy is still in free-fall, and everywhere rough beasts, their hour come, slouch towards Bethlehem so you’d think there would be a lot to discuss on serious news outlets but based on four or five obvious facts that were a revelation to no one and only surprising to those who have been living in caves for the last twenty years we were treated to solid, 24-hour coverage of nothing and less than nothing about a guy whose life was really not that complicated and whose death was mundane by celebrity standards…save for the revelation that Diprovan, an induction agent for anesthesia and medical paralysis, is now a recreational drug.

About the only real interest I have in the whole affair is whether and when Michael Jackson’s doctors are going to jail.

You’ve Got to Know When to Hold ’em

As many of you know I am done with residency and am back in Louisiana working as an Attending Physician in a small but very busy Emergency Department. We have a lot of casinos in our fair city which got me thinking that Emergency Medicine is a lot like high stakes gambling. We are dealt a hand with every patient and after glancing at it, must figure out what kind of cards the patient is holding; whether the guy with chronic back pain really has an epidural abscess or whether he is bluffing, and make our workup and disposition judgments accordingly. We can’t admit everybody, we can’t run every test on everybody all the time, and as this is still a rational world (but getting more insane every day) eventually the majority of patients will be sent home where a certain percentage of them will have a bad outcome from something that we missed because it never occurred to us or from something that we anticipated as a possibility but about which the patient decided to eschew follow up as directed.

I mention this because I actually send people home with no lab work or imaging studies whatsoever which is something I probably only did a handful of times as a resident. I had, for example, a young boy brought in by his father for intermittent abdominal pain for the previous two days, particularly while playing sports, but who presented with no complaints whatsoever and a normal physical exam complete with a benign abdomen, normal testicular exam, normal digital rectal exam negative for occult blood, normal vitals, normal, normal, nothing, nada, zilch.

Could he have had something? Functional abdominal pain? Gastritis? Intermittant testicular torsion? Sure. But he had excellent follow up, reliable parents, and no complaints whatsoever brought in mostly for parental concern and because it was a Saturday and their pediatrician wouldn’t see them until Monday. I felt it was safe to send the kid home because, and maybe I’m wrong here and I will be bombarded by dire warnings from my colleagues to the effect that I am playing with fire or I will change my practice habits the first time I am sued (but did I mention the kid had no complaints and a stone-cold normal and extremely comprehensive physical exam?), on some level our job has got to involve using a little common sense. In this case understanding that the kid was not sick, was in no danger of dying, had vigilant parents who lived only a mile from our hospital with access to a phone, and really had no business being seen in the Emergency Department except that most Emergency Departments are now mostly after-hours clinics with some really sick patients thrown in three or for times a shift to slow things down and keep the waiting room backed-up.

With that being said, I still admit the usual patients with vague complaints who meet certain criteria for age, comorbidity, or reliability. I’m not stupid. But I’m trying, like I said, to use a little common sense.

We have the usual variety of patients but, while we have much less trauma than at my residency program, many of our patients are actually quite sick. I have run quite few codes, intubated often, and have done a lot more procedures on a daily basis than I did as a resident for the same number of patients. I’ve had, for example, quite a run of febrile infants with Fever of Unknown Origin requiring lumbar punctures and several of them panned out as meningitis.

Procedures are a lot easier as an attending in a non-residency hospital. I tell our most excellent nurses what I am going to do, they get all of the stuff ready (the most time-consuming part of most procedures), and they don’t even let me dispose of my own sharps after I am done because, as the charge nurse told me, “Don’t you have some patients you could be seeing?”

A resident’s time is not worth much, in other words, but they aren’t paying me now to hunt up gloves and syringes. We are incredibly busy most of the time and like residency I work non-stop for my entire shift.

My first patient was a woman with vague abdominal pain and an elevated white count who I did actually send for a CT scan (normal of course) but eventually sent home with instructions to return in twelve hours if not significantly better. My second patient was a young lady on oral contraceptives and a smoker with a month of worsening breathing difficulty, chest pain, and “cellulitis” of her calf a month before. Wouldn’t you know that her EKG showed the classic strain pattern (“S1Q3T3”) that you never are actually supposed to see and I naturally started her on Heparin (an anticoagulant) almost as soon as I got her history, being rewarded shortly with an angiogram that showed exactly what I thought it would: big pulmonary emboli (clots) in the arteries of her lungs.

The family thought I was a genius but this one was obvious, an incredibly easy (but very satisfying) diagnosis that in our age of vague complaints presenting far in advance of any classical signs and symptoms is something of a rarity. It’s the minor complaints that really give me fits.

Bread and Circuses, Water and Sewage

Customer Disservice

There are days when I explain to the family of a 98-year-old customer, in terror of the the inevitable end, that today is not that day and while the odds of their mother living another month are close to zero, she’s alert, reasonably comfortable, and they have some time to say what they want to say and do what they want to do.  There are also days when I must gently insist to a family that despite what they have heard about the mighty apparatus of American Medicine, it will be as ineffectual as casual prayers and there is only time now to steel their hearts and accept the inevitable end.

And then there are days when a simple customer, sorted in triage as a minor complaint, slowly evolves into a horrifically complicated ICU admission whose fragile life depends on the skill and vigilance of the entire Emergency Department staff…and even then the odds are not good.  That one will keep me in the Department long after the end of my shift, the extra hours of which gain me nothing materially.

On every day we risk our health in this dangerous profession where we are exposed to the concentrated sickness of the entire city.  We risk our careers, too, and our economic viability making thousands of decisions about customers with more medical problems and more medications than I once believed could burden one human being while held to a standard of care that tolerates no mistakes; the slightest of which (something as simple as not giving an aspirin) not only has the potential for disaster but can start the long, expensive slog through the court system where every victory is Phyrric and defeat, the out-of-court settlement, is always the preferred outcome.

And then nobody really pays us for our work although the usual drunks and serial abusers of Emergency Services, customers all,  loudly proclaim at the slightest affront to their august dignity that they are “paying our fucking salary.”  There are co-pays for some and none for others and some boldly steal medical care, the thought of paying one thin dime for the services of at least the highly-trained nurse who they regard as their personal servant having never entered into their head; medical care being, after all, just another public utility like water and sewage and nobody pays for those things.

The bureaucrats at my hospital have just gone through their annual mission statement contortion and have, on schedule, given birth to the usual smarmy slogan which is going to change the direction of the hospital and solve every one of its problems by focusing on the customer…putting the customer first…taking the customer seriously…making the customer the center of our efforts…making customer service a priority…ostensibly to increase customer satisfaction but more realistically because it is cheaper than hiring nurses to take care of the customers we’ve already got.

But this isn’t Wal Mart and the patients are not customers. Pretending they are degrades the patients and dehumanizes the practice of medicine by substituting clinical judgment and perception with the polite fiction that we are engaged in nothing more than a business transaction, one in which the customer is always right and which is now to be ruled by Press Ganey and Mammon, the Two-Faced God-Incarnate of the bureaucrat.

Come On Now…

92-year-old patient.  Demented.  The usual medical problems teased out of the the nursing home medication list and the family who insisted he was healthy except for the pacemaker, the feeding tube in the belly, the coumadin for a “heart problem,” the three strokes, the diabetes, and the emphysema (but he’s 92 so he must be doing well).  History of benign polyps in his colon.  Presented for abdominal pain after a colonoscopy earlier that day.

Why does a 92-year-old man with less than a fifty-fifty chance of living another year get an expensive colonoscopy?  I mean, it had better be a good reason.  Rectal bleeding.  Something like that.

“It was a screening colonoscopy,” said the consultant, “We removed a polyp.”

You have got to be kidding.  Remind me never to send you another patient.  Would it have killed you to have politely deferred the colonoscopy for another year just to see how things would shake out?

Of course, I was no better because I ordered the deluxe work-up with all the usual laboratory tests and the premium CT scan although his abdomen was benign and he was too demented to really get a handle on his exact symptoms.  In my defense and contrary to popular belief, please note that I don’t get extra money for ordering a lot of tests.  But I still squandered your children’s money, money which really belongs to our Chinese and Arab creditors and future masters, at a blistering pace.

My job is mostly ridiculous, on some levels anyway.  At least we sent the gentleman home instead of admitting him like the family wanted, “just  to be safe.”

“Just to be safe.”

The four most expensive words in all of American Goat Rodeodery.

We Just Get Headaches

I had a pleasant conversation with a recent immigrant from Cuba whose wife came to the Emergency Department with a severe headache that she volunteered was the worst of her life and had started abruptly.  Naturally with this kind of history and some reasonably high blood pressure we brought the Great Ship of American Medicine about and raked her hull with a full broadside of medical ordinance.  We were looking for a ruptured cerebral aneurysm and it took a CT scan of the brain (negative), a lumbar puncture (a “spinal tap”) which was equivocal, and finally a Magnetic Resonance Angiogram (MRA) of her cerebral vasculature to definitively prove that there was nothing really serious going on and she just had a bad headache.

The cost (to your children) was immense and on the way out the husband, who was extremely gracious and not a little impressed at the our thoroughness, shook his head in amazement and said, “You know, in Cuba we just get headaches.”

“We used to just get them here too,” I replied.

Something About the Culture of Medical Training

One of our junior residents did a particularly fine job of intubating a patient who had, to put it mildly, an extremely difficult airway.  You know, 600 pounds, no neck, a beard, and instant hypoxia when laid flat.

“Nice job,” I said after we got everything secured and the the patient moving towards the ICU.

The nurses looked at me in horror.  “Good Lord,” they seemed to say with their eyes,  “Don’t praise the residents, they might get big-headed.  Don’t you know you’re supposed to beat them down at every opportunity?”

Just thought I’d share.


Marching Up Country

(With Apologies to Xenophon)

The campaign draws to a close and will end like many such expeditions do; in a victory of sorts for I have certainly marched into and through the Empire of Medicine with my fellow mercenaries, outwitting the enemy on many occasions, laying waste to his crops and orchards when necessary, and always keeping one step ahead of his mighty armies that sought to harass and encircle me.  And yet the cost has been immense and I arrive at the end of this journey with treasure sorely depleted, footsore, battered, and weary with miles to go until I am truly home.  Still, having survived this far seems a monumental achievement although at the time it was just a slow slog through inhospitable lands, a wretched journey punctuated by moments of excitement and terror.

Now crest the last hill and view, stretching to the horizon, the glittering waters of the Black Sea beckoning to us like a welcome friend and a reminding us that that we have now come through the worst part of it although many adventure still lie ahead.

The sea!  The Sea!

What I Now Know

Most of the job of any doctor is ridiculous. So ridiculous in fact that to get through the the day it is necessary to engage in a little doublethink as you pleasantly churn your way through the reams of useless paperwork, the incredibly asinine patients who you treat just for placebo’s sake, the waste, the inefficiency, the bureaucracy, and every manner of obstacle between you and what you must occasionally convince yourself is a meaningful job.  I know this very well.

Occasionally I give narcotics to an obvious drug-seeker or start an enormous work-up on a patient who is surely a malingerer and the nurses give me that sarcastic, rolling-their-eyes kind of look to imply that I am too trusting of the patients and if they were in my position they’d throw the bum out with a couple of Tylenols and big glass of water.  Fair enough.  Cynical they may be but they are usually spot-on in their assessment of who is really sick and who is missing some essential gonadal chromosome.  Although frequent fliers and malingerers occasionally present with hidden but extremely severe acute medical problems, for the most part they and the constant procession of patients with minor complaints need no more of a workup but a good history, a focused exam, and an admonition to return without fail if their symptoms don’t improve.  I suppose that most of them don’t need to be seen at all and surely not in an Emergency Department.

In other words I know full well that most of the money with which we hose down the patients is poorly spent and completely ineffectual.  I understand this.  I get it. Thanks for ripping off the scab and rubbing salt in the wound.  You do whatever it takes to get through your day but for my part, it is often necessary to suspend my disbelief and pretend, for sanity’s sake, that every abdominal pain, vague back pain, nebulous headache, and strange constellation of non-specific symptoms is going to pan out; is going to reveal itself to be that one in twenty cases that justifies all of this education, all of the hours, all of the money dumped into my training, and the devastation of my personal life.

Even the Bumper Stickers Suck

Used to be that the most durable object on the planet was a bumper sticker.  So durable that they often outlasted the car.  In fact, you can still see the occasional Clinton-Gore offering, slightly faded but robust, grimly adherent to a lovingly maintained Nissan Sentra.  I mention this because I still see the occasional Obama bumper sticker proudly displayed by the vestiges of those still in abject thrall of the Serpent King Ra-Obama and although it has been less than a year, the stickers are faded, peeling, and look like something printed hastily in some North Korean re-education camp before the entire shift was taken out and shot.

Which is sort of a metaphor for Obamerica, a country that is rapidly turning into a crappy third-rate nursing home where nothing is made, nobody does anything of value, and the only growth industry besides government are breathless special interest groups working hard at the kind of socially conscious jobs beloved of neighborhood organizers, vying for and spending money we borrowed from the Arabs and Chinese to mold another generation of Americans into beggers, whiners, and shrieking social parasites.  The country is kind of peeling at the edges and fading, so to speak.  Even the Russians are laughing at us, completely baffled at our headlong rush into Marxism, statism, socialism, and all of the other -isms that  once, long ago when we were men, we defeated handily.

And the Sun-God hasn’t a clue.

Like I said, even the bumper stickers suck.

Edumucation and Other Things


While driving through the downtown of our small but not insignificant Midwestern city (there are corn fields five miles from the city center but we do have the state capital and a handful of miniature skyscrapers) I noticed a fat brown squirrel scampering down a tree and bounding across the street in the halting but graceful manner that can only be executed by a squirrel.   From between two buildings a large hawk dove at the squirrel and, opening its wings and rotating its talons forward at the last second, grabbed the squirrel by the head nearly decapitating it from the violence of the attack.   It flew back into the skyline with the limp body of the squirrel swinging from its claws.

My friends, the squirrel is us, you me and everybody bouncing along through life in our own halting, occasionally graceful manner.

The hawk is death.


Our good blog-friend Cosmic Connie over at Whirled Musings brings up an interesting point about the proliferation of easily obtainable on-line and mail-order degrees.  I think she is just scratching the surface of the problem.  While it is easy to identify fly-by-night diploma mills, most of what is considered legitimate higher education in this country is essentially the same thing; a lot more expensive with better ambiance and legions of fawning admirers but diploma mills just the same.

In fact, if there is a bigger scam than higher education or one supported by such a collection of self-interested grifters (who nevertheless bask in public adulation) I have yet to hear about it.  In terms of shadiness, only the CHIP program, an offshoot of Medicaid designed to funnel Other People’s Money into lucrative Pediatric Emergency Departments and Children’s Hospitals purpose-built to loot this rich bonanza even comes close.  Indeed, just as most of the money spent on the goat-rodeo of American Medicine is mostly wasted, most of the money spent on higher education is also mostly just thrown away producing little benefit to society except the employment of fearsome armies of educational bureaucrats who would otherwise be fit for nothing but agricultural labor.

That and serving as federally subsidized day care for 18-to-24-year-olds who would otherwise be inflating the unemployment statistics, safely warehousing them for another four years as sizable majorities of them pursue Mickey Mouse degrees.

Even prestigious universities are mostly now nothing but diploma mills and federal student aid farms where anybody who qualifies for student loans will be fed into the pipeline to emerge at the other end with as much money squeezed out of them as possible. If you think it is otherwise you are sadly deluded. A modern university is a self-perpetuating bureaucratic octopus, growing bloated as only an organization with unlimited access to public money can, and requiring only one thing: a steady supply of warm students shoveled into the front end to be kept in the mill as long as possible.

And the price of a degree keeps going up, outpacing inflation, not because the quality of the educational product has improved but because there is so much federal loan money available to pay for it.  The suckers keep lining up to borrow hundreds of thousands of dollars for easy, meaningless degrees that give them something to put on their resume when they apply for a job at Starbucks.  There used to be educational standards but now there is a university for everyone and a Mickey Mouse degree to be had at any level of educational ability and for any level of scholarly ambition.  May as well get a mail-order degree and save yourself the tuition.

The relevance to Goat Rodeodery?  Only that maybe the string of initials after everybody and his brother’s name may not mean as much as was once believed.  Certainly the number of initials, abbreviations, and credentials listed on a hospital identification badge is usually inversely proportional to real education.

You Missed It…

Every week or so I get a comment or an email from someone who was once passionate about the idea of Emergency Medicine but after reading my blog decided to eschew it in favor of some other specialty.

Unfortunately, I may have given the wrong impression about Emergency Medicine. It is true that much of American medicine is either a cruel grind or sublimely ridiculous.  Keeping this in mind however, Emergency Medicine is a blast.  It has everything: Sick patients who really need your help and are mighty appreciative of it. Absolute medical train wrecks who, tenaciously refusing to shuffle off their mortal coil, are dumped onto you with the expectation that you can and will squeeze just a little more functionally pointless life out of them.  Shootings.  Stabbings.  Every manner of human virtue and vice.  Minor complaints.  Serious complaints. Ridiculous complaints. Really, really ridiculous complaints.  You name it, we’ve got it and to reject the never-ending passion play and freak show of Emergency Medicine is to avow a certain disinterest in mankind, a desire to have nothing but sanitized interactions with your patients who have been scrubbed clean (often literally) and filtered through the Emergency Department.  People are generally on their best behavior in a clinic or the wards (or at least their better behavior) but in the Emergency Department we see them in the raw; man primordial, folly and nobility magnified.

But you have to love chaos.  I’ll give you that.  Not that the department is chaotic all of time but every now and then when the waiting room is packed and the ambulances keep rolling in with more critical patients, when the Friday night drunks are particularly demanding and the drug-seekers exceptionally whiny, when you are short-staffed and the charge nurse is making fists at you to move your many patients either in or out; when the impatient families are growing angrier by the minute and everybody is feeling harassed and overworked…when everything seems to be devolving into mayhem, confusion, and carnage you had best be able to prioritize and multitask like a friggin’ supercomputer or you probably actually won’t like Emergency Medicine.

The hurricane rages and blows.  Huge waves slam onto the deck as the rigging comes down around your head and the ship wallows in a following sea.  You are either the kind of lunatic who laughs at the gale and spits in the wind or this kind of thing intimidates you and you can only cling to the mast in terror.  I exaggerate of course but we have had off-service rotators in tears at various points of their brief exposure to Emergency Medicine.

Another Pet Peeve

“You goddman doctors killed my mother (who is sixty-two years old, on hemodialysis three times a week for kidney failure, has bad congestive heart failure, is blind and has double below-the-knee amputations from the ravages of diabetes, has had so many strokes in the last two years that the neurologists just stand in the door and sigh, is recovering from her fifth heart attack, has been in the intensive care unit six times in the last two years, and had a very  challenging case of pneumonia which was probably the result of aspirating the chicken soup her daugter fed her even though her strokes have made it difficult for her to swallow and all of her nutrition is poured into a tube going directly into her stomach).”


“I got the Swine”

I’m hoarse from explaining influenza to my patients, the numbers of whom showed a small but significant increase over the last two weeks as Swine Flu hysteria grew, peaked, and then receded.  Everybody wanted a pill for “The Swine” for which, unfortunately, there is none except an essentially useless anti-viral that works but has to be given almost before you even know you are sick to have any effectiveness.  Antibiotics are useless against a virus of course and I spent hours explaining to my patients who, being mostly products of the public school system, had no clear idea of the difference between bacteria and viruses or even what these tricky sounding things were in the first place.  To their credit they had terrific self-esteem and confidence in their ignorance so the schools must be doing something.

Undaunted, I came up with all kinds of simple analogies to explain the difference between bacteria and viruses. I thought I was doing pretty well but invariably they would smile, nod at the crazy doctor, and ask for some antibiotics.

Simply because it is the first instinct of the public to seek safety at the Emergency Department I think if we ever have an epidemic of a dangerous and essentially incurable viral illness we are all screwed .  Going to the Emergency Department during an epidemic is exactly the wrong thing to do if all you have is a sore throat and some sniffles.  Some of your fellow citizens sitting next to you in the packed waiting room may actually have Ebola and when we invariably send you home with Motrin and our best wishes you are going to spread it to everybody in your house.

What we need is a public awareness campaign to keep people away from hospitals during an epidemic.   At least we need to put triage out in the parking lot and not in front of the triage nurse’s counter.  That way we can send the not-that-sick or not-sick-at-all home without exposing them to everybody in town.

I’ve got news for all of you: If things get really bad there’s not much The Man can do to help you anyway and if you are old, multiply co-morbid, or unhealthy you will probably die as there are not enough ICU beds or staff who will show up to work to take care of you.

Super Users Revisited

I know everybody and his brother is outraged at the examples of lone-gunmen patients who make so many Emergency Department visits that the cost of their care runs into the millions but the problem is actually much bigger than that.   While the Super Users are an obvious problem, they are also something of a red herring.  Sure, they cost a lot of money but as there are not that many of them we could conceivably solve the problem with a little creative but humiliating bribery (say a permanent suite at the best hotel in Vegas which would be a bargain compared to the alternative) or a couple hundred bucks to the right seedy character and no questions asked.

The real problem is the patients who don’t rise to the level of Super User but nonetheless spend a significant amount of their time trying to wrangle an admission for chronic medical problems, an admission that, as it involves 24-hour care, hot-and-cold-running-narcotics, room service, and chambermaids and butlers who dress like nurses is viewed as something of a vacation from the daily grind of anticipating the next disability check.

I almost always look at the List of Previous Visits before I go see a patient, just to see what I’m dealing with you understand.  It is, for example, useful to know that the last time your asthma patient came in he had to be intubated and spent a week in the Intensive Care Unit.  This kind of information keeps you on your toes.  Lately I’ve noticed quite a few patients coming in for what turn out to be minor complaints who have twenty or thirty Emergency Department visits in the past couple of years, also for what were presumably minor complaints as they were frequently sent home without admission.  Not enough visits to rise to the level of Super User but how many times do most people go to the doctor, much less the Emergency Department, in a couple of years?

I’ve seen a doctor four or five times in the last thirty years but I have so far enjoyed good health.  On the other hand I have patients who have quite a few medical problems but still manage to get through a year with only four or five doctor visits and trip or two to the Emergency Department.    Would twenty doctor visits a year for chronic but easily controlled medical problems be considered excessive?  How about four or five admissions, most of which were probably incredibly weak and more to ward off the legal vampires than for any sound medical reasons?

Anecdotally, and take it therefore for what it is worth, I would say that if I excluded my incredibly co-morbid patients who would die if not symbiotically grafted to every hospital in town as well as the handful of people with rare and unstable conditions, at least a third of my patients have a rather large number of visits, seemingly out of proportion to their medical history.

Don’t get yer’ shorts in a bunch.  I’m just throwing it out there.  But the wails and gnashing of teeth when medical care is finally overtly rationed as it must be under any system where it is given away for free will rend the very stones…and not just from the patients either.  Money drives medicine and the steady flow of government money cannot possibly continue.  Somebody is going to start saying “No” one of these days.

My Pet Peeve

You came to the emergency Department by ambulance, sirens blaring and tires squealing.  You were in excruciating pain, so much so that the ten-point pain scale was inadequate and you swore it was a “twenty out of ten.”  You clutched your chest (or your abdomen or your head) and I, taking you extremely seriously, initiated the Million-Dollar-Workup to find a heart attack (or an aortic dissection or a intracranial bleed).  I poured pain medication into you and stood ready to resuscitate you when you finally succumbed to whatever horror had you in its deadly grip.

So please, a scant half hour after your arrival and while we are well on our way to proving that all you had was a little bit of gas or maybe some particularly vicious esophageal reflux, please do not stand outside the door to the critical care/trauma bay asking when you can go home and demanding food.

Dude, you were dyin’ twenty-five minutes ago.  Can you wait another half hour for a sandwich?

Can’t Touch This…

Actual Patient Conversation:

“Man, that Dilaudid didn’t even touch my pain.”

“Uh, Okay.  Your CT was negative so you’re fine to go home.  I’ll ask your nurse to come discharge you.  Come back if you get light headed or start to vomit but otherwise, just take Motrin for your headache and you should be fine.”

“Can you give me a prescription for Vicodins.”

“No.  If the Dilaudid didn’t even touch your pain then this must be the kind of pain that doesn’t respond to narcotics and a couple of Vicodin would be useless…I mean Dilaudid is one of the most powerful narcotics we have and it didn’t do a thing.  Stick to the Motrin.

“How about some Demerol.”


Another Actual Patient Conversation:

“Vicodin doesn’t even touch  my pain.”

“I’m sorry.  That’s all I’m going to prescribe.”

“Can you give me a ‘scrip for my Methadone?”


“Well, how ’bout a shot of somethin’ before I go?”


“Aw, man.  Fuck you.  I want to speak to the manager.”

“Sir, this is not the International House of Pancakes.”

Darn You, Manny Rivers!

More than the usual number of incredibly sick, incredibly old, incredibly senile, incredibly decrepit, and incredibly still alive patients today.  There must have been a convention because for the first half of my shift the average age of my patients was around 86 and between the eight of them they had 112 distinct medical problems, 38 doctors, 26 artificial joints, six pacemakers, 18 coronary artery stents, and, as three of them had ileostomies, only five functioning rectums.  The presenting complaint for seven was some variation of decreased mental status and one had stroke-like symptoms consisting of a slight facial droop although it was later confirmed that this was an old finding, first observed during the Clinton Administration.

A couple of the families were reasonable and declined any further medical care except hospice but the rest wanted “everything done” and committed us to expensive and extremely futile workups and admissions; three of the patients in particular went to the Intensive Care Unit where they are even now laying insensate and demented in their cocoon of medical equipment, either spending their grandchildren’s money or screwing our Chinese and Arab creditors depending on how likely you think it is that we can ever pay back all of the pretend money we are printing to pay for this insanity.

A day in the ICU costs Medicare approximately $4000 once all the costs are factored in.   A week or two and we’re talking serious money, much of it totally wasted in the sense that many of the patients on whom it is spent have almost no chance of ever leaving the ICU and, if they do, will be essentially vegetative until they finally die.   ICU charges under Medicare are in the Neighborhood of 40 billion dollars per year and rising.  Medicare itself spends around 300 billion per year, almost half of that for hospitalizations of all kinds.

I blame Manny Rivers and his surviving sepsis campaign.  Sepsis is an infection that leads to shock  and, until very recently, was largely fatal especially in the elderly who regularly succumbed to septic shock from bad urinary tract infections or pneumonia (so much so that pneumonia was once know as the “Old Man’s Friend” as it regularly relieved the suffering of the senile and bed-bound).  Dr. River’s great gift to medicine was what now seems like a simple method to aggressively treat sepsis that has significantly decreased mortality, extending the lives of many patients who would have otherwise been almost untreatable.  The foundation of his method is a five or six liters of inexpensive Normal Saline and, stripping away all of the fancy equipment and the flashing lights, that’s pretty much it.

While generally a good thing, especially as I have seen many elderly septic patients returned to the full enjoyment of their glorious old age, just because we can do something doesn’t mean we need to do it all the time.  I don’t always know when care is futile and I am not so arrogant to think I can judge the worth of anybody’s quality of life but there are some cases that are so obviously futile, that for example of a nonagenarian  whose every bodily function comes through and out of a tube and who hasn’t so much as moved purposely in a couple of years, that what we do is not only insanity from an economic point of view but also from a human decency one as well.  We do what the families want, however, rational or not.  First because we are conditioned to never give up.  Second because we have surrendered a great deal of medical decision making to the patients and their families even if they are not qualified to make the decisions and, more importantly, as they are not paying for any of their treatment have no skin in the game.  Third because we are afraid of the legal implications of withdrawing care, so much so that hospitals have ethics committees for the rare occasion when enough is enough whose principle purpose is to spread the liability.

And fourth, as there is a lot of money changing hands there is little incentive for hospitals not to aggressively treat everybody who comes in.  It’s either that or have ICU beds sitting idle generating no revenue whatsoever.

But the madness needs to stop.  What we need is a Futility Scoring System, perhaps a simple sum of points given for co-morbid conditions and age above which only comfort care or home hospice will be reimbursed by Medicare.   And it needs to become the standard of care.

Now if we could only find someone to put the bell on that damn cat.

More Random Reader Questions and in Which I Give Some Real Medical Advice Without Fear of Being Sued

(Actual questions from actual readers. -PB)

I know you don’t like chiropractors but what are we supposed to do for chronic back pain?

For chronic back pain I recommend back strengthening exercises, instruction in correct lifting and posture, weight loss, physical activity, judicious use of NSAIDs, and occasionally just sucking it up.  For serious back pain which may be the result of a herniated disk, tumors, or occult fractures, I recommend imaging to assess the possible source of pain and such medical or surgical therapy as an orthopedic surgeon may suggest. I’m certainly not sending somebody with a lumbar fracture or ankylosing spondylitis to a chiropractor which would be like going to the barber to have your transmission serviced.  It just makes no sense.  Most back pain is usually self-limiting, however, and resolves in a few weeks without intervention of any kind.  With this in mind, what’s your chiropractor really doing for you?  Nothing.  Neither is the doctor who enables your narcotic addiction, especially when he writes you a prescription for vicodin just to get you out of his hair.

I am becoming seriously zero-tolerance for handing out narcotics for chronic back pain.  It’s your primary care doctor’s job anyway and I’m not really qualified to do it.  Oh, and I don’t buy the bullshit stories about allergies to Motrin and other non-narcotic pain medications.   A patient who is allergic to everything but Dilaudid (essentially legal heroin prescribed by a physician) is a drug-seeker, period.

What is the secret to good health?

Don’t smoke, don’t stuff dangerous recreational drugs into your body, if you drink do so in moderation, eat a healthy, varied diet without resorting to fads and supplements, and exercise as regularly and as vigorously as your health will allow.  Also, get outdoors into the fresh air whenever you can, have an interesting hobby or two if your job doesn’t fill your need for creativity, and get regular sleep.

The rest is just marketing.  You don’t need to eat organic foods or make a fetish out of being “natural.”  Additionally, all the fish oil and vitamins in the world probably won’t make a bit of difference to your health and if they do, the effects will be marginal and not worth the effort and expense.  Good health is mostly common sense, inexpensive lifestyle choices, and genetics.

Eat a fucking steak every now and then.

What do you think of Emergency Department “Super Users?”

The reader is referring to a recent story detailing how just nine patients made 2700 visits to Central Texas Emergency Departments over the course of six years.  That’s roughly one visit per week per patient for six years.  First, I assure you that this sort of thing is not confined to Texas.  I work at two different Emergency Departments and I see my share of “frequent fliers,” some who I have seen multiple times at both departments and usually for what turns out to be either nothing or a minor exacerbation of a chronic medical problem for which they are also seeing their primary care doctor  (although to be fair I have intubated one guy seven times in the last three years).

The next question is why do these people keep sucking down medical resources?

The answer is: “Who cares?”   Are many of these Super Users mentally ill?  Sure, some are.  Do they have real medical problems?  Of course they do.  But what does it matter, really?  If they are so sick and so crazy that they suck down a million apiece in medical care, most of it wasted and money that is not available to people who need it, then they need to be institutionalized for their own good because they obviously can’t handle life in any rational manner…except of course they are rational enough to know that they can never be turned away from an Emergency Department and structure their lives accordingly.  I say this because every proposal suggested to correct the problem of Super Users does not address the real underlying problem, namely that personal responsibility and civic virtue are no longer required of any citizen and, despite being a nation  of a million little rules and regulations, no effort is made to enforce even the slightest amount of common-sense based decency.

In other words, the solution to the problem of Super Users is not to coddle them even more by coming up with yet more government initiatives to essentially beg and bribe the parasites on our system to pretty please stop wasting more medical resources in a month than most people have used in their whole lives, but instead to cut them off at the knees; something that we could easily do, perhaps placing a limit on Emergency Department visits after which you become an automatic Get The Hell Out, except the legal environment is such that it has now become a right to squander as much of the public treasury as you possibly can.   It is one of the biggest ironies of American life that while on one hand the productive sector is now supposed to be collectivized, subordinating their rights as individuals to the benefits of their labor in order to provide a living to the non-productive sector, to suggest on the other hand that citizens engaged in criminal abuse of society by essentially stealing collective money should be punished will bring out the usual braying from the defenders of irresponsibility, now screaming about the rights of individuals and how collectivization of responsibility is unacceptable.

Tea Party Update

I was surprised at the turnout.  I live in a small Midwestern city of about 100,000 and there must have been 20,000 people at the Tea Party.  It was a very nice, enthusiastic, but well-behaved crowd of mostly what looked to be working class and professional people with the odd scattering of Viet Nam veteran bikers who are obligatory at this kind of thing.  Very few freaks and the few I saw were actually very nice college kids who dressed like goth punk rockers but were quick to assure me that they were College Republicans at our local Big State University.

There was no counter protest, at least none that I saw.  One had been planned but I think the people who showed up for it saw the size of the crowd and said to hell with it.  I did talk to two well-dressed, well-spoken law students who, they said, had been sent by ACORN to “infiltrate” the rally.  The people around us laughed good-naturedly at this as not only did nobody care but the place was so packed a mouse couldn’t have infiltrated too far.  They tried to debate and then got sort of haughty, brandishing their superior academic credentials as proof that we were all misguided but within ten feet of me were two other doctors, a chemical engineer, and couple of lawyers so that generated more polite laughter.

I saw them drift away looking perturbed.   Liberals sometimes live in air-tight bubbles and I think they were a little surprised that the crowd was not composed of toothless hicks clinging to their Bibles and guns while waving the Stars and Bars.

Incidentally, if ACORN is now getting federal money, what were they doing proselytizing at a political event?

Don’t Forget….

A short post today, my apologies, but I want everybody who can to attend their local “Tea Party” on April 15th.  As you may recall from American history, back in 1773 American colonists irate over increasingly oppressive duties and tariffs imposed by the British disguised themselves as indians, boarded British Merchantmen in Boston Harbor, and threw their cargo of tea overboard, protesting among other things taxation without representation.

Taxation with representation ain’t so hot either and, as Washington is now completely in the clutches of our home-grown criminal class, I’d like everybody who gives a crap about liberty, free enterprise, and stopping the conversion of our country into just another European mammary state to gather with your fellow citizens at your city’s tea party.

Keep the following in mind:

1.  Although the tea parties are being touted as “Conservative” events and their will be many conservatives there, you don’t have to be completely conservative to go.  They are more and expression of Libertarianism but conservatives share some similar values so it’s cool.

2. Keep yer’ pro-life, pro-gun, pro-whatever stuff at home.  I’m pro-life and pro-gun but this is not the day for it.

3. Be polite to the handful of counter-protesters.  They will be freaky and transgendered looking and they will be advocating as many issues as their are protesters, most having nothing to do with taxation, but that’s just their thing.  I have been to many conservative events and without exception conservatives and Libertarians are well-dressed, polite, well-spoken, and behave in a way that makes our events family friendly.   I have never seen the police have to use pepper spray, dogs, or any intimidation at all to control conservative crowds (in fact most cops are probably on your side) so let’s make it a pleasant day for everybody including the police.

47 Million Uninsured My Ass

(With apologies to Deborah Peel -PB)

So I had this uninsured patient with a chronic medical problem that was being addressed at The Big Academic Medical Center Sixty Miles Away who came to the department with worsening symptoms from her chronic medical problem, a problem that was competing, I might add, with several others that were lifestyle related.  No problem, of course, because people can’t choose when they are going to get sick and if we have to fill in for The Big Academic Medical Center Sixty Miles Away then so be it.

An expensive workup ensued which confirmed the worsening of her chronic medical problem.  Score!  A slam-dunk admission.  A pleasant phone call to the admitting physician who, even though it was 3 AM would agree, ruefully and without the usual surliness and rolling of the eyes that it is our lot to elicit in every doctor in town at one time or another, that the patient really was sick and really did need admission.  Unfortunately, as soon as I mentioned the patient’s name he related to me that at her last admission for a similar exacerbation of her chronic medical problem she had eloped, leaving the hospital and her doctor’s care because she believed she was being treated rudely. On her way out she had sworn to “never let them touch me again.”

A week after her elopement and while visiting her sister at the Big Academic Medical Center Sixty Miles Away (a sister who interestingly enough had the same chronic medical problem), she checked herself into their swank Emergency Department for a similar worsening of her chronic medical problem and was admitted; receiving an expensive workup and, on discharge, a follow-up appointment with one of the Leading Specialists in the Field of Herchronicmedicalproblemology, a lady who has written textbooks and who had followed her at the Big Academic Medical Center Sixty Miles Away.

The admitting physician adamantly refused to admit and suggested, not unreasonably, that I transfer her to The Big Academic Medical Center Sixty Miles Away as they were the last to lay hands on her and were most familiar with her condition.   The Big Academic Medical Center Sixty Miles Away agreed, without hesitation, to accept her and I even spoke to the Leading Specialist in the Field of Herchronicmedicalproblemology who happened to be on call.  Oh how the heavens sometimes align and, just when you think you are heading for a knock-down, drag out patient transfer brawl you see the triumphal field just ahead and prepare to eat the cheeses and hams of victory!

Unfortunately, despite having no insurance, no ability, and no intention of ever paying a thin dime for the hundreds of thousands of dollars of free medical care that she has received and will receive until that tragic day when the treasure we spend will only bore the Reaper, the patient refused transfer to The Big Academic Medical Center Sixty Miles Away citing a litany of complaints against them from rude nurses to bad food, perhaps most damning being her observation that the Leading Specialist in the Field of Herchronicmedicalproblemology didn’t know what she was doing and, “Didn’t do nothing for me.”

Not to mention that the one hour drive would inconvenience her family, their constant attendance with cell phones at ready being a necessary adjuvant therapy for her chronic medical problem.

Oh my gentle readers, scholars all and deeply interested in this insane goat rodeo known as American Medicine, you would have wept at the sincerity of our efforts to prevent her, unsuccessfully, from eloping and leaving the department to nestle in the bosom of her uninsured family.  There may be 47 million uninsured (most of whom are young enough to never require expensive medical care or wealthy enough to afford insurance except they have other priorities) but this particular one of them was so unconcerned for her own health that she spurned our best efforts over a matter of overblown pride and convenience for the many visitors she expected.  Is she typical of the uninsured?  Maybe not.  But we can and do move heaven and earth to care for all of our patients, even those who cannot pay. I have never heard of a patient who needed treatment being turned away which is why a wino living on the streets of our country can receive medical care that European politicians living in The Health Care Paradise Across The Water have to fly to other countries (ours) to get.

Ask Yer’ Uncle Panda: More on Mid-Level Providers and other Topics

(In which I answer several random questions submitted to me by readers. -PB)

Hey, Panda, I’m not sure what specialty I would like to do and am considering going to PA school because Physician Assistants can easily move between specialties.  Your thoughts?

I often hear the ease of movement between specialties touted as a benefit of being a Physician Assistant or other mid-level provider. The theory is that if you find yourself bored in, say, primary care you can easily find a job in a different, more interesting, or more lucrative specialty.  By contrast, changing specialties as a physician is a long, incredibly arduous undertaking. The only way, for example, an internist can credibly practice as a cardiologist is to complete an additional three year fellowship on top of his first three years of residency.  If, as another example, I wanted to practice as a surgeon I would have to apply for and complete an additional four years of residency training assuming any surgery residency program would take me which, because of the way medical training is funded, they probably wouldn’t.   A Physician Assistant, on the other hand, can get a job with a cardiology group and a few days later, mutatis mutandis, he is a cardiology PA.

Nothing wrong with this of course. The role of a Physician Assistant in many specialties does not require the depth of knowledge of a physician and I repeat, as many Physician Assistants are hired to do the relatively low-skilled grunt work of a practice this depth of knowledge is not required. But unless we’re going to revisit that magical world where two is bigger than four, five years of residency is no different than a little on-the-job-training, and superior knowledge can be had without learning all of that useless stuff, the ease of moving into different specialties should only indicate that a certain…how can I put it…comprehensiveness is not required of a Physician Assistant.

Which is not exactly a ringing endorsement of the depth of Physician Assistant training although if that’s your thing, go for it.

But Panda, can’t Physicians Assistants do 90 percent of what a doctor does?

No.  Although to be fair they can do 90 percent of the paperwork so, since fifty percent of my job consists of useless bureaucratic tasks, ipso facto they can do a large part of my job.  The conceptual difficulty many of you have is your lack of understanding about the structure of the goat-rodeo-cum-cluster-fuck known as American medicine in which there are three broad specialties.  The first is actual, honest-to-Jehovah Medicine of the kind we all imagined we would be practicing long ago before we actually started wrestling the proverbial pig.  You know, things like diagnosing and treating diseases using good clinical judgment and appropriate testing and consults.

The second specialty is Tort Medicine which is something we do continuously in an effort to minimize the perceived risk of being named in a lawsuit for a bad outcome that may or may not have been our fault.  As this primarily involves throwing vast quantities of money at our patients in the form of useless, unnecessary, or only marginally helpful studies and procedures in an attempt to uncover every single thing that could possibly be wrong with the patient (no matter how unlikely), I see no reason to doubt that Physician Assistants can handle these tasks admirably, the number of boxes you check on the order sheet being often inversely proportional to your knowledge of real medicine.

The third and largest specialty is Boilerplate Medicine in whose service we devote countless hours charting, documenting, and filling out reams of redundant forms, the main purposes of which are to legitimize billing and keep millions of low-level administrators gainfully employed.  It is in this specialty where mid-level providers particularly excel and for which most are hired.  What are most History and Physicals for routine admissions and procedures, after all, but loads of useless information, grimly documented for the insurance company, surrounding a kernel of important facts?  Unfortunately, since you can’t bill insurance companies or the government with a concise paragraph describing everything important about the patient, we have developed check boxes and forms that codify useless information and organize it for easier parsing by bureaucrats; even though for strictly medical communication all most doctors need and would prefer is a brief paragraph.

Or, to look at it another way, I am now after eight years of medical training capable of writing a brief, elegant, and succinct paragraph describing everything you need to know about the patient as well as my assessment and plan which any other doctor can read and understand completely.  If this was all I had to do I could probably see twice as many patients but unfortunately, the government and private insurance companies (not to mention the lawyers as there is considerable overlap between Tort and Boilerplate Medicine) need their medical prose like a sailor needs a happy ending and if I can hire a relatively cheap mid-level to crank it out then so much the better.

The real question should be whether someone needs a two-year Masters degree (in the case of Physician Assistants) or one year of fluffy smugness (in the case of Nurse Practitioners or Doctor Nurses or whatever the hell they want to be called) to essentially fill out a bunch of mostly useless paperwork?  Surely if clinical skills are not that important, and that’s exactly what a mid-level is really telling you when he insists that his two years of training is equivalent to your seven or more, then we could probably save a heap o’ wampum by training motivated Community College students for an exciting career that we can call “Physician Assistant Assistant” (or PAA) and eliminate the expensive mid-level middleman.

But what about Primary Care?  Surely mid-level providers are suited for primary care?

You only say that because you don’t understand primary care or are confusing it with something else.  Primary care physicians should and ought to have the highest level of medical knowledge and clinical instincts because they are not specialists and therefore have to be fluent or at least conversant in all of the medical specialties.  To the extent that they aren’t is only a reflection on the nature of American Goat Rodeodery where reimbursement and the predatory legal environment makes referring to specialists a de facto requirement for a primary care physician’s financial survival.   With this in mind, most specialists are used not in their intended role as sage consultants for particularly difficult cases but as extenders for over-worked primary care physicians, meaning that they primarily see nothing but fairly routine patients with bread-and-butter conditions that the patient’s family doctor simply did not have the time or the legal gonads to address.  In this respect mid-level providers are probably better suited to the specialist trade, and the more specialized the better, because it is easier to acquire a superficial knowledge of a highly specialized field than of a broad, non-specialized one.  I know, for example, a Pulmonary Medicine Nurse Practitioner whose entire job is to set patients up for bronchoscopy, the pulmonologist’s signature procedure and biggest money-maker.  Realistically, however, I could train a high school student to do most of her job.

Now, it is true that primary care physicians see a lot of minor complaints.  Hell, I’m an Emergency Physician and I see plenty of them too, some so trivial that it would drive one crazy if it weren’t for a sense of humor or plentiful, cheap whiskey.  In fact, a substantial subset of the patients I see have complaints that are not only minor but only twenty years ago wouldn’t even have been considered the kind of medical problem for which someone would legitimately seek medical attention.  Can a mid-level provider handle these?  Of course.  But are they sure they want to make the motto of their profession, “Mid-Level Providers: Wrangling Patients that Don’t Really Need to Be Seen So You Don’t have To?”

Primary Care, in other words, is not just about minor complaints and it is not urgent care either.

What About Urgent Care?

Urgent Care is mostly a scam, at least in cities that have functioning Emergency Departments and I would advise most of my patients to avoid them as an unnecessary and costly middleman.  With a few exceptions, if your complaint is minor enough where it can be addressed in an Urgent Care Clinic you probably didn’t need to be seen at all and whatever treatment was prescribed is just a placebo, something to show that we care or to keep you amused while nature takes it course.  If your complaint is legitimate or even the slightest bit threatening the practitioner running the place will default to his legal protection mode and refer you to the Emergency Department, off-site Emergency Department triage actually being the only legitimate medical function of Urgent Care clinics.

Can you get a school sports physical at an Urgent Care or a note from your doctor as an excuse when you miss work?  Sure you can.  But these things are worth what they are worth.  The work note is worth nothing medically and the cursory sports physical as it will never pick up any but the most obvious reasons why you might drop dead while playing basketball, fulfills what is mostly a bureaucratic requirement and not a medical one.   This is why, by the way, residents love moonlighting at Urgent Care Clinics.  Namely because it pays pretty well, the stakes are low, nobody is really sick, and if they are you can easily punt to a higher level of care.

What about Complementary and Alternative Medicine?  Can’t I go to Chiropractic School or something like that if all I want to do is primary care?  My Chiropractor advertises himself as “Primary Care” so I was just wondering.

Complementary and Alternative Medicine is mostly modern superstitious drivel marketed to people who are, in their knowledge of science and reason, no better than seventh century peasants except that Dark Age peasants had an excuse to be ignorant as they had marauding Norsemen competing for their attention.   On the other hand most people don’t think about medicine that much and have no reason to distrust their chiropractor so allow me clear something up for you: Chiropractors, naturopaths and other Alternative Medicine practitioners do not have the same training and education as medical doctors, not in quality and not in quantity, not by a long shot, and therefore they are not qualified to serve as primary care physicians, a job that requires more than some haphazard study of herb lore or a cursory knowledge of the spine. If they had the same training including residency training they would be qualified…but they don’t so they’re not.

Take your typical chiropractor, for example.  He has a four-year degree at an institution that was probably nothing but a federal student loan processing mill in which the odds are he never saw a really sick patient, at least not one that wasn’t immediately taken to the nearest Emergency Department.  Unlike your Family Physician who has four years of medical school followed by an intensive three year residency, your chiropractor has never rotated on a pediatric ward, in the Intensive Care Unit, on an internal medicine service, a surgery service, or any other of the medical services in which the core knowledge of every physician is developed.  He has done no call, been responsible for exactly nothing during his brief pseudo-medical training and has never had to make a decision that mattered to anybody.  More than likely he slithered through chiropractic school making a mental list of the many, many things he would never have to worry about (I mean, assuming he was introspective enough for this) and that he would defer to real doctors.  He is, therefore along with his naturopath cousins eminently unsuited to recognize, diagnose, and treat general medical complaints.

The funny thing is that I would never try to pass myself off as a surgeon, an obstetrician, an internist, or a neurologists because I lack the training and knowledge to honestly represent myself to the public as something I am not…and yet naturopaths, chiropractors, and the whole pack of Snake Oil Salesmen with a fraction of the training required for the job lack the humility, the self-awareness that comes with an appreciation of their own limitations, to consider that maybe, just maybe, they don’t know enough to be primary care physicians.

No doubt your Chiropractor can fill out forms with the best of them and correctly bill your insurance company but if you have a medical problem serious enough to warrant treatment you should see a real doctor and eliminate the useless middleman.   Likewise if you really care about your long-term health.

Not to mention that the primary treatment modalities of practioners of Complementary and Alternative Medicine are extremely ridiculous on a fifth grade biology level.  To believe in them, things like subluxations and Reiki, is to place yourself in the company of drooling cretins.

1001 Ways to Die

1001 Ways to Die

There has got to be a better way to die and surely the patient at the center of our frantic activity couldn’t have wanted this one.  I arrived at his room with a code in progress although, as the patient was still alert, most of the activity involved throwing towels on the floor to soak up the large quantities of ink-colored blood pouring from his mouth, his nose, and the edges of his adult diaper.  The patient was obviously in severe respiratory distress and one of our junior residents who was running the code prepared to intubate, securing the patient’s airway and providing ventilatory support being the first most reasonable step to…well…I don’t know what except that the family wanted everything done even though no power on earth could reverse what was ordained by cruel nature and metastatic cancer.

As the patient opened his eyes for the last time, gaping in horror as he drowned in his own blood, I’m sure he saw gibbering death slouch into the room, leer at the nurses, and settle into the shadows with a smirk on his face to enjoy the end of the show.

Then, as suddenly as turning off a switch the patient was gone which naturally didn’t stop us from ineffectively performing half an hour of violent maneuvers on his body and throwing all manners of potent but useless medications into it before the family, huddling in terror just outside the door, were convinced and asked us to stop.  We slid a breathing tube into his trachea, rammed a  big intravenous line into his femoral artery, crammed him full of fluid, ran electricity through his heart, and bounced him around his stool and blood-soaked bedding; only pausing to look hopefully at the monitor for cardiac activity even though he was glassy-eyed and had that dead look about him.  Our junior resident even optimistically ordered some O-negative blood (which is what you give if you don’t know the blood type) from the blood bank but we weren’t exactly holding our breath for it to arrive from the deep basement labyrinth of the hospital.

If you can believe it, the desperate struggle against failing organs now at an end, he looked better dead than alive but then, as I first saw him crouching on a bedside commode moaning in terror,  I didn’t exactly catch him at his best.

Eternal God Whose great mercy endures forever. Spare me, Your devout but occasionally wayward servant, from this kind of death and grant that I may die peacefully in my bed.

Why People Love Complementary and Alternative Medicine

I had a patient the other day with some very mild conjunctivitis (“pink eye”) which, in otherwise healthy adults is almost always-and I mean the planets align when it’s not-viral or from some other cause that is untreatable except for symptomatic relief.  After checking her visual acuity, verifying that her pupils were normally reactive (to exclude iritis which is a big deal), and even doing a completely unnecessary slit-lamp examination of her cornea I was able to give her the good news that her condition was benign, required nothing but symptomatic relief, and would almost certainly resolve completely in the next one to two weeks without the need for topical antibiotics (which we often prescribe even though the evidence for their effectiveness even in the case of mild bacterial conjunctivitis is less than compelling) but only some mild analgesic eye drops.

The patient balked at the thought of one to two weeks, “Won’t the medications you’re giving me make it heal faster?”

“No,” I explained.  The eye drops just offer relief of symptoms but nothing we can do will shorten the duration of your conjunctivitis. It’s very mild, we don’t really know what’s causing it, and you should be fine.  If it gets worse you can see an ophthalmologist or even come back here.”

“Can’t you give me something to make it heal faster?”

“No,” I explained.  The eye drops will just offer relief of symptoms but nothing we can do will shorten the duration of your conjunctivitis. It’s very mild, we don’t really know what’s causing it, and you should be fine.  If it gets worse you can see an ophthalmologist or even come back here.”

And so it went for five minutes after which, not convinced, the patient allowed that she would be paying a visit to a well known local Wellness Center, a shameless emporium of every form of snake oil I have ever heard of, where no doubt the magician on duty will provide some magical potion or Eastern herb that will miraculously cure her conjunctivitis in from one to two weeks.

And yes, Gentle readers, there are people in our sad and rapidly deteriorating country who will come to the Emergency Department at two in the morning for mild, and I mean mild, “pink eye.”

Old School and Other Things

Old School

I admire the physicians of yesterday who practiced at a time before medicine became so technical but I don’t necessarily accept the premise that they were better doctors.  Certainly their physical exam skills were better honed than ours are today as this was often all they had to establish a diagnosis.  They also had a much better grasp of eponyms, being able to rattle off this triad or that pentad  and their significance to the patient; often pointing out some obvious but rare eponymous physical exam finding to nail the diagnosis.  On the other hand I have a sneaking suspicion that their patients weren’t on such a hair-trigger to see a doctor and many conditions probably festered a bit until the constellation of presenting symptoms more closely mirrored what you would expect (and still see) in the textbooks.  In other words, it is one thing to confidently identify a patient deep in the throes of acute hemorrhagic pancreatitis by observing Grey Turner’s Sign (bruising on the flanks) but quite another to diagnose the same in a patient who may be early in the disease and has come to the Emergency Department or his doctor’s office with nothing but mild abdominal pain and a vague history.

Which is how it is nowadays.  In the Golden Age of Medicine, an era that is fading even from the memories of our oldest attendings and in a time before life had become medicalized to the degree it has today, since it was accepted that doctors couldn’t do much patients tended to stay home until something was obviously wrong.  A patient came in with nausea, vomiting, fever, and severe pain in the right lower abdomen and Bam! Acute appendicitis or nothin’.  Today the pain is mild, the location is somewhat more generalized, and while we may not be as ready with the eponym, our differential diagnosis has to be a tad more comprehensive and the work up, because of the legal consequences of missing a diagnosis not to mention the availability of sophisticated tests and imaging as well as appropriate interventions, needs to be more exhaustive.  It is the exhaustive nature of American medicine, the now firmly established belief that everything is an emergency, that contributes to the high cost of everything we do and I’m not sure if the money we spend has really bought us that much, at least not in relation to the vast sums of money that we continue to dump into the sucking pit of medical care.

I mention this not because I necessarily believe that preemptive vigilance is a bad thing, just that it is an extremely expensive way to practice medicine and it may be that a little more of a guarded approach, a commitment to watch and wait might save a lot of money with no effect on morbidity and mortality.  Surely, as an example, every woman early in her pregnancy with some spotting and mild pelvic pain does not need a full workup for an ectopic pregnancy although if you come through our department and have any of these symptoms, even if your chief complaint was a sore throat, you will have a full battery of expensive tests to rule it out.

Do I take ectopic pregnancies seriously?  Of course I do.  But I’d say that I probably initiate twenty negative workups for every ectopic I find and the positive ones are often clinically obvious with the studies ordered to confirm the diagnosis.   The question is whether waiting a day or two would effect the outcome and whether the occasional benefit of early detection is worth the money we spend ruling out the majority that turn out to be nothing but a little bit of pain from a stretching uterus and a bit of normal physiological bleeding.  Like I said, you can present to any emergency Department or doctor’s office with symptoms so vague that a doctor sixty years ago wouldn’t know what to do with you but today receive a full work-up, no different than if you had waited a few days and your symptoms were more classical.

Getting A Job

Just a few observations about looking for my first post-residency job and with a hat-tip to the folks over at M.D.O.D.:   First of all, it was a pleasant experience after applying to medical school and residency to interview for a job from a position of strength.  You essentially have to beg to get into medical school because you hold no cards whatsoever and no matter how stellar a student you were or how winning your personality, there are many more qualified applicants than there are spots and it may as well be somebody else who gets picked.  Likewise with landing a decent residency position which is, like medical school admission, something of a poodle show for graduating medical students as we trot ourselves from program to program trying to convince them that we are good dogs.  Not a lot of negotiating going on, your understand, both medical school and residency being exclusively “take it or leave it” propositions….at least I never heard of fourth year medical student with so much clout that he could negotiate a residency contract (which is not really a contract at all but a documentation of indentured servitude) to his liking.

As a board-eligible physician however it is more of a seller’s market.  In my specialty there are many more jobs than there are Emergency Physicians to fill them so once you get out of the subservience mode (and certainly by the end of your residency you should be pissed off enough to not want to be every body’s little bitch all the time) you can get, within reason, any kind of job with any kind of pay that you want…all you have to do is recognize that your prospective employers need you more than you need them and act accordingly.  I am not, mind you, advocating arrogance or unreasonable salary demands, just that it is no longer necessary to beg.  In the end, you can walk away from any offer with complete impunity and no hard feelings as long as you negotiated in good faith.

Negotiating is the key.  In most cases the first number they slide across the desk or put into a draft contract is a tentative offer and most employers will not be offended by a little dickering.  Likewise with signing bonuses and even simple things like moving allowances.  Sometimes your prospective employers will offer these things up front but if not, there is no harm in asking for them or any other legal and reasonable concession.  The worst they can say is “no” and the worst you can do is respectfully decline their final offer.  Again, no hard feeling, nobody is worse for the wear.

Your room to negotiate also depends on where and for whom you want to work.  Many markets for Emergency Medicine are saturated and if, for example, you just have to live San Diego you may have to settle for a lower salary than your colleagues looking for jobs in Klamath Falls. The rules of supply and demand do not, after all, always work in your favor.  The same would apply if you wanted a junior faculty position at a Big Academic Medical Center in which case you would have to sell yourself shamelessly and probably settle for a good deal less than you could make somewhere else.

There are also many kinds of practice.  You can sign on with an established group with the intent of becoming a partner, you can work directly for a hospital system as their employee, you can work as a free-lance killer-for-hire locum tenums, or you can work for a hospital as an independent contractor to name just a few options.

Obama Watch: The Love That Dare Not Speak Its Name

“Man-caused disaster” instead of “Terrorism” is the latest euphemism to come out of President Obama’s administration, in this case from his Secretary of Homeland Security, and shows, as if you needed any other evidence but the last eight weeks, with what a pack of morons we are dealing.   Maybe they’ll reconsider the term when Obama is surveying the glowing ruins of an American city destroyed by Alleged Foreign Perpetrators or whatever the euphemism will be for the terrorist group that manages to smuggle a nuclear device into Chicago.

I mention this because I live in an area where the Cult of Obama is very strong and yet, the other night I observed my neighbor furtively scraping the Obama bumper sticker off of his Subaru.  I think people are catching on, in other words, although there will always be the die-hard cadre of fanatical followers who dress their children in paramilitary garb and have them chant paeans of love to the Dear Leader.  My neighbor is not that fanatical however and is a decent enough guy even though his political and economic knowledge is sketchy and based largely on earnest but meaningless slogans.  He probably only voted for Obama because he didn’t know what else to do.  Surely he couldn’t have voted for that old, mean Republican who had a clue but didn’t whisper such sweet nothings into his ear.  Now, in the post-coital period when he lies vulnerable and afraid while Obama is in his kitchen drinking his beer and checking his black book my neighbor feels used and a little dirty.  He’s given it up for a guy who is just not that into him and will never return the love that was so desperately given.

Which is also the trouble with the press.  Although Obama is barely two months into His presidency and involved in scandals that make anything since the Nixon administration look like patty cakes, the paleomedia, our own professional cheer leading class, are still starry-eyed and hoping that their lover will come back for one more roll in the hay that will lead to consummation and justification (Peggy Noonan comes to mind).    I mean seriously, the Obama administration and their enablers in congress took bribes from AIG to pay their bonuses from the recent pork-laden stimulus bill, directly adding provisions to the reconciled bill, and the outcry from the press?  Tepid at best.  Politics as usual.  Ho hum.  President Obama gets a pass because, shucks, the bill was a thousand pages long and how could the Smartest and Sexiest Man in the World be expected to know what His own government is doing?  I shudder to think what it would take to get meaningful reaction out of them who were once the savage watchdogs of our democracy but have now abrogated that role to talk radio.

The press now lays prostate and sticky with sweat, wondering if it was worth it and hoping that The One will come to his senses and love them as they love Him.

Skin in the Game and Other Things

Skin in the Game

I had the privilege to work with one of the specialists in town for the last couple of weeks, a gentleman who still takes call for the Emergency Department but only for one week a month after which we have to ship the emergency cases in his particular area of expertise a hundred miles away to the Big University Medical Center.  His specialty is much needed, vital to our patients, and although there are others with the same qualifications in town, their unwillingness to expose themselves to our patients says a lot about the perverse incentives and obvious disincentives of the goat rodeo known as American medicine.

I followed him in his clinic, assisted him in the operating room, and generally learned a lot and had a good time even though he noted that I have no surgical instincts whatsoever, something that I freely admit.  Because he is at the top of the medical food chain and separated from my typical patient population by several layers of lower-order specialties, his patients were a refreshing change for me.  Almost without exception they were polite, well-spoken, and if not always well-educated at least imbued with the native common sense that at one time was highly prized in our country.  Not only that but they were wonderfully, almost unbelievably, compliant with their follow-up and care plans and the most common thing I heard in two weeks at the clinic was some variation of, “It’s getting better and better. Thanks Doc.”

Either that or, mirabile dictu, “Hey Doc, when can I go back to work?”

The only exception to this were some of his patients for whom he was called into the Emergency Department.  Suffice to say that if you sustain the kind of injury for which his services are necessary while drunk and fleeing from the police or beating your lesbian girlfriend at two in the morning you are probably not a model citizen, insured, or likely to be an ideal patient.  We had one patient like this who on follow-up the next day, surrounded by an irate fleshy phalanx of her extended family,  immediately informed me of her intention to sue the motherfucker who had operated on her.   Naturally my specialist is stuck with this lady as he had laid hands on her and now owned her medical problem until the bitter end; neither will he receive a dime for either the procedure, his time rounding on her in the hospital, or for any of her many follow-up visits over the course of the next several months to a year.

Conversely, when we refer a patient to him for a non-emergency complaint, he will not see this patient for free.  He doesn’t take Medicaid either because the reimbursements are so low that he can’t keep the lights on if he gets swamped with this kind of patient.  The bureaucratic requirements for compliance as well as the restrictions on his ability to practice medicine the way he wants are also particularly onerous and contribute to make Medicaid much more than just a money-losing enterprise; accepting it turns a doctor into a poorly-reimbursed indentured servant.  But he does take charity patients, only asking that they make a commitment to him to show that they both respect his time and abilities and have an interest in their own care.  This commitment is 250 dollars up front to get in the door.

Now, to the shrieking harpies of social justice this sounds incredibly crass.  How dare anyone expect the Great Unwashed, the victims of 230 years of institutional oppression, to cough up some money for a basic human right that should flow as easily as water from the tap?  On the other hand, as I have yet to meet a Medicaid or uninsured patient who couldn’t afford cigarettes, liquor, and many of the other irregular pleasures that it is our legal obligation to subsidize, the fact that a referred patient will stand in the waiting room hurling epithets at the receptionist and threatening to sue because he was asked to pay a little bit for a service without which he will be permanently disabled only shows that his priorities are perhaps a little skewed, the motto of The People having now become “Hundreds for luxuries but not a dime for my doctor.”

All that is being asked is that this fellow put some skin in the game.  Of course, “Skin in the Game” is nothing more than the usual doublethink from the Sun king, Ra-Obama and his pantheon of minor governmental deities.  As our country devolves into nothing more than a crappy nursing home for the care and feeding of the chronically helpless, the only people who are really expected to have skin in the game are those who already have a considerable amount of it in the game already.  You can’t, for example, possibly have more skin in the game than I do.  Not only have I spent four years of residency going into debt providing medical treatment for the Holy Underserved but people like me, suckers that we are, have worked our whole lives to support the entire creaking edifice of entitlement and greed that is the modern mammary state.

Exactly How Stupid Are Medical Students?

Medical student debt and the fear of it is a red herring and just another cynical ploy by The Man to punk you. It is no different than trying to make the excessive work hours and sleep deprivation of residency about Patient Care. In the case of excessive work hours and sleep deprivation the argument is always framed in terms of what is best for patient safety; the mantra being that we have to limit hours only because patients are harmed by tired residents and not because sleep deprivation is, by itself, cruel and unusual punishment and a practice that would lead to arrests if it were discovered in some illegal sweat shop.  The problem with using patient safety as a reason to let residents sleep is obvious however.  All The Man has to do is show that patients are not harmed or that the frequent patient hand-offs required when residents work rational hours are more dangerous and you are now stuck working under conditions that are considered war crimes if forced on prisoners. You have unfortunately allowed someone else to dictate the language and subject of your debate.

Now consider medical student debt. Realistically, most medical students don’t incur that much of it, at least to the extent that it is unmanageable. It is what it is and in my specialty with what I will be making,  it is just a a cost of doing business, a fee I will pay every month for access to a lot more money than I could have made at my previous career. Pace the argument that medical student debt is a looming horror that will impoverish us all, I consolidated the federal portion of my loans at a truly ridiculous interest rate which is so low that it makes no sense doing anything other than paying it off with excruciating slowness, always with the very real possibility that I will be dead of old age before I am done.  Actually, a couple or three years of inflation like we had in the seventies and this portion of my debt will, in relation to real income and purchasing power, disappear as a serious concern.

Would I have accepted a pittance from the government as a salary if they promised to make medical school free? Of course not. The very question is also a tool of The Man and his useful idiots in medical education to frame the debate in their terms. You will agree, strictly from an irrational fear of debt, to have your education paid for and in exchange, the sanctimonious government will dictate your salary, paying you less than you would make even subtracting debt.

And you’ll be stuck because you took the money and now you have nothing to say.

Jeez.  Why don’t you all think things through before opening your cake holes?

I’m Back

I am in the final days of residency training having less than one hundred days to go before I am, after eight long years, finally finished with this great ordeal that has cost me almost everything I have and the completion of which is looking to be one of the great anti-climactic experiences of my life.  On June 30th I will finish my last shift as a resident and three days later I will start a similar shift someplace else but for about ten times what I am making now.


I have learned a lot in the last eight years, some of it I didn’t want to know and the ignorance of which was probably better than the full knowledge I am acquiring of it.  I had no idea, for example, how unconcerned many people are about their own health and with what gusto they ignore common sense, their doctors, the frantic signals from their rapidly collapsing bodies, and any crumb of knowledge they may have gleaned from their ineffectual sojourn through that useless warehouse optimistically known as the public schools.  I am also still amazed at how incredibly sick people can be and at how many different diseases and dysfunctional organ systems can be supported in one patient who nevertheless manages to hang on grimly (or maybe obliviously) year after year while an increasing amount of medical care is sprayed on the burning house (metaphorically speaking).

And I have also learned about the corruption of our system, the unavoidable consequence of the many competing players, most of whose interests are irreconcilable and stem largely from the the titanic sums of somebody else’s money dumped into medical care coupled with the public’s insatiable avarice for it.  That most of the money we spend on medical care is wasted is also becoming clear to me and it is on these and other more entertaining topics I hope to continue writing.

I also want to welcome The Macho Response as an official partner of Panda Bear, MD.  It’s hard to exactly describe this blog.  It’s author, the self-styled Crack Emcee, is not a doctor but he does have a common-sense based grasp of medicine.  He is not a scientist but has the intelligence to know both when smoke is being blown up his ass and to point out the hypocrisy and puritanical tendencies of many in the scientific community.  He is an atheist (where I am most certainly not) but he is intellectually consistent in his principles and has not given up “old-fashioned” religion only to latch onto some nutty cult as is too common in our sad and ridiculous age.

The Crack Emcee is an artist of some note, however, and his blog is a sort of collage, an exploration with links, pictures, and music of the truly ridiculous behavior and ideas of those truly ridiculous individuals in the various elites who style themselves our superiors, our protectors, and our benevolant masters.  Be warned, however, that his blog is not for the spineless products of our apologetic and insipid culture.  You will be offended.  You will shriek in dismay as your icons are defaced and your tin-plated heros are gutted in his arena with their entrails left to cook in the hot sand.

Don’t say I didn’t warn you.

Welcome to the Pandaverse

(The Student Doctor Network has been kind enough to host the archives of my blog and have asked me to write a little introduction. I’m sort of retired as a blogger so in lieu of a post I thought I’d just answer a few questions that people often ask me. I may from time to time write an article but I assure you it will be with nothing like the frequency I used to. I’m enjoying being a former-blogger too much for that. -PB)

Tell Us a Little About Yourself.

I am an an Emergency Medicine Resident Physician in my fourth and final year of training. I am a little older than most residents having come late to the medical profession.

Do you like being a doctor?

Sure. It’s not a bad job. The pay is decent once you get out of residency and despite the conventional wisdom, physicians are almost universally respected. The pay will naturally vary by specialty and the respect depends on your ability to project those intangible qualities that the public expects but it’s not a bad gig if you can stomach some of the less savory aspects of it.

What are some of the less savory aspects?

First you have to realize that most of any doctor’s job is pure bullshit. I can’t exactly quantify how much but it is definitely more than half and probably closer to seventy-five percent. It’s not just the ridiculous bureaucratic obstacle course constructed by the hospitals, the insurance companies, the government, and various quasi-official regulatory bodies like the despicable “Joint Commission” (for whom is reserved a special circle of perdition) that contribute to this huge proportion of bullshit, nor is it the depredations of the legal profession who’s pervasive influence has driven common sense out of the system, but rather the bullshit is a combination of these things and the worst impulses of human nature allowed to run unchecked in a society like ours which has finally liberated its citizens from personal responsibility.

On a practical level, this means that out of every dollar that passes through your hands, seventy-five cents of it may as well have been flushed down the toilet for the all the good it does. Some goes for the reams of useless and entirely ridiculous paperwork that is the joy of administrators and the pushing around of which employs them by the hundreds of thousands. Some goes to completely unnecessary testing which is ordered for the sole purpose of defending ourselves from the inevitable lawsuit that will ensue if we miss either a rare condition or a highly unlikely, exceedingly rare presentation of a common disease. Most of it, however, is spent on the margins either overreacting to fairly trivial complaints or spending large sums of money on therapies and procedures which have limited effectiveness in terms of decreased morbidity or increased quality of life.

Not to mention that the system is fairly corrupt and If you really knew how corrupt it was you wouldn’t be so eager to devote your life to it. For our part, as physicians we shamelessly waste money on unnecessary consults, weak admissions, and redundant tests because that’s where the money is. While some of this can be blamed on the legal profession which forces us to practice highly expensive defensive medicine, we need our paying customers and, insomuch as a weak admission or an unnecessary colonoscopy pays as much as a legitimate one, there is no incentive for doctors to turn patients away, even those who will only benefit marginally or not at all from all the money we dump on them. We revile EMTALA, for example, as it has buried most Emergency Departments in trivial complaints but it is these trivial complaints that are now the lifeblood of our specialty and have made it one of the most lucrative.

On the part of the patients, they are mostly terrifically entitled and want everything done all the time regardless of cost and regardless of effectiveness. They are looking for a magical antidote for what are mostly lifestyle related illnesses and, as they are not directly paying for any of their medical care, have no incentive to not come to the doctor for every little thing.

The industry itself is corrupt because its primary function is to garner as much money from the public as possible. Most pediatric emergency departments, for example, are built for no other reason than to suck up as much CHIP money as can be legally squeezed out of a steady stream of minor complaints.

Wow. Is there anything good about medicine?

Of course there is. We operate in a deeply flawed system but that doesn’t mean we have to either like it or worship at its twisted altar. I try, for example, to practice good clinical medicine and am leery of ordering studies and consults “just in case.” Of course, I have never been sued and human nature being what it is, the first time I am burned the temptation will be to cover my ass with the best of them, spending millions of dollars of your money to protect mine. On the other hand, as our program director often tells us, he’d rather defend himself in court having used good clinical judgment and sound medical practice in the face of a bad outcome than to have “checked every box” on the order sheet hoping to prevent the lawsuit. At least, as he tells us, he can sleep at night.

There is also no question that we occasionally do some good. After a month or two of resuscitating septic, severely demented octogenarians, returning them to their pre-death warehouses for a few more months of laying in their own excrement and gaping at the ceiling, we recently saved the life of a septic teenager who made a full recovery and has nothing in front of him now but his future. And we occasionally get some real medical problems..heart attacks, congestive heart failure, lacerations, trauma…good stuff but watered down by a majority of patients who seem to have shown up at our doors because they really have nothing better to do on a Thursday night. Either that or they have established a parasitic relationship with the vaunted social safety net of which the Emergency Department is the only representative that is open twenty-four hours a day.

Would you do it over again?

No way. In fact, if knew back then what I know now I would have laughed and thrown my medical school application in the trash. Like I said, I like being a doctor but the toll on my family and my marriage has been immense. Things are getting better but as my wife pointed out to me, and which is something that I have heard echoed by many other residents and their wives, when I get home from a shift in the Emergency Department I have given so much to my patients…so much attention, concern, conversation, humor, grief, and every other kind of human interaction…that I have nothing left to give to her. You think of course, you who dream of touching hundreds of lives and doing good in this bad old world of ours, that this is a good trade but I assure you that medicine as a profession will not love you back. You can solve the medical problems of a thousand grateful patients but a few hours after they leave the department or are discharged from the hospital they won’t remember your name or even your face. You will be just another bucket of medical care that they received from the tap like any other public utility.

I also don’t want to discount the tremendous economic toll the last eight years have had on us for which, of course, I have no one to blame but myself as nobody held a gun to may head.  Still, it is hard to know exactly what you you are getting into when you first start.  Certainly as I have a family and the usual responsibilities and expenses that this entails I expect that many of you who do not will not face some of the same challenges.  When medical school and residency is just a continuation of college and you feel comfortable living in a crappy apartment with milk crates for furniture it is probably a lot more bearable from an economic point of view.  Yes, medical school debt accumulates but it’s really not that much all other things being considered and you are actually payed what is technically a decent salary as a resident, at least one upon which a single person with no responsibilities can live.

But as a medical student and resident with a large and growing family?  It is virtually impossible to make ends meet and we have been going steadily deeper into debt for the better part of the last decade.   I have no doubt that we will eventually dig ourselves out but the opportunity cost, a cost which includes lost wages and debt, for this little adventure has been enormous and we will arrive on that fine Summer day next July when I start making a decent salary way, way behind where we should be at this stage of our life and marriage, that is, with no savings and no assets except what’s going to be left in our checking account.

Flat-busted, in other words.

What Do You Think Of Universal Health Care?

Heck, we already have it. What we really need is less of it. For a start everybody should have to pay real money for their own primary care. It is completely ridiculous that we pay for the routine medical care of a growing population of people who will spend three-hundred bucks a month for cigarettes not to mention other irregular pleasures but who regard a twenty dollar copay or a hundred bucks here of there for a visit to a Family Doctor as a monstrous injustice and an assault on their human dignity. Not to mention that we give away free medical care to people who have no business getting it.

I had a young patient the other day who was collecting disability for something we would have laughed at thirty years ago who has used more free medical care, most of it unnecessary I must add, than people four times his age who are really sick. There are probably whole Cuban villages that have collectively used less medical care. And yet he regularly opines that things will be so much better when medical care is free.

What? Are they going to give him a gold-plated bedside commode? Is the nurse going to give him a massage? Will he be seen quicker? Get more narcotics with fewer questions? What more does he want?

What is the Biggest Problem Facing American Medical Care?

Our inability to say, “No.” No, your eighty-year-old severely demented father with a list of medical problems that reads like a pathology textbook cannot get a colostomy to divert his bowel movements away from the large sacral decubitus ulcer eating into his sacrum. No, we will not spend a hundred thousand dollars of critical care extending your life by two months. No, we will not keep your relative on the ventilator until your family can fly in from all over the country to be at the bedside. No, we will not pay for routine pediatrician visits when not only are they not necessary most of the time but cost less than you spend every month for cable television. No, we will not work you up for abdominal pain when you were sound asleep when I walked in your room, surrounded by hamburger wrappers, and all you really want is an ultrasound of your baby to show your friends. No we will not admit you for the eighth time this year for chest pain after seven negative work-ups. No, we are not your drug-pusher and some problems in life, believe it or not, are not medical at all.

Until we learn to say “No,” to ration care honestly and not covertly, we will exhaust the treasure of our nation and further mortgage our prosperity to the Mandarins of China and the Sheiks of Araby who will one day decide that your free medical care is not such a good investment after all.