Saturday, February 23, 2008

No Cookies for You

I’ve just spent the last 7 minutes lying on my bed, trying to zip up my new pair of jeans. Now I’ve got them zipped, but not buttoned. They are the same brand, size and style that I’ve always worn, but obviously Levi’s is trying to save a few pennies by using less fabric in the manufacturing of their jeans. It has thrown the sizing all out of whack. It couldn’t be that I’ve been eating like a little piggie for the last six weeks. I’ve been working so much that I haven't been eating regular meals. Eating junk food is easier and faster than eating right. And now it’s Girl Scout cookie season. Damn Girl Scouts and their cookies.

Thursday, February 21, 2008

My Brainscan

I have a confession. I never go to the doctor. If I don't feel good, I Google my symptoms, prescribe an Advil for myself, and I am cured. No big deal. Now I don't even have to leave the house to get my brain scanned. I can do it myself over the Internet.

[Hmmm, I wonder if I took my brainscan to the ER, I could get some of the "good" stuff they are always writing about. It's not like they would have to spend a lot of time and money examining me. I've already done the hard part. I just show up with my brainscan, they take one look at it, see I'm obviously in need of pain meds for my headache. . . ]

Sunday, February 17, 2008

Dr. February is . . . Charity Doc -- Part 2

We're back with Part 2:

Q.4 What is the weirdest, craziest, most insane thing you have ever seen while working in the ER?

A.4 Gosh, I've seen so many whackos and weirdos. Rarest diagnoses I've ever made on the same day: Acrodermatitis Enteropathica secondary to Zinc deficiency on a little baby, and Copper deficiency due to excessive zinc ingestion (Zinc-induced copper deficiency) on a different patient. I was studying for my board exam that day during a slow shift in the Pediatric ER and was just flipping through the dermatology atlas when this Hispanic infant was brought in for a chronic rash that hadn't gone away after application of antifungal cream, etc... This was their 5th visit and my first time seeing the kid. The rash was so pathognomonic to the point that I said, hey Hey HEY, I just saw that in a book! Later that shift after I had read up on zinc metabolism and deficiency, a sick looking adolescent was brought in by his mother for lethargy and a litany of nonspecific complaints. Turned out the kid had been having a flu like illness and had been pounding down over-the-counter zinc supplements repeatedly. A Zinc deficieny and Zinc overdose all in the same day. Talk about serendipity favoring a prepared mind!

Freakiest, craziest, most insane cases I've seen? Well the guy who swallowed a bunch of pennies that I blogged about (and posted the xrays) was pretty crazy. Then there's also this schizophrenic guy who wanted better reception with the mother spaceship so he stuck hundreds of pins into his scalp and all over his body. The xrays were quite bizarre. Then there's that story of "The Two Jesus" when 2 guys in the psych. holding area of the ER beat the crap out each other after each claiming that they were the real Jesus. That was pretty hilarious. And who could forget the guy who walked into the ED with a kitchen knife sticking out of his forehead between his eyes (I still have the xrays and pics). And also the guy who walked in from triage with a meat cleaver stuck to his head. And also through triage, the guy who walked in with an ax stuck to his back. They all survived, BTW. I've already posted on my blog about the guy who walked in with a kitchen knife in his back buried to the hilt but it turned out to be all subcutaneous as the blade bent when it struck his spine. Then there was the guy who was tied by the foot and dragged by a pick up truck for several miles. That was quite gruesome.

The Monica Lewinsky scandal was so hilarious for us as it brought out a bunch of old schizophrenic ladies claiming to have had "sexual relations" with Bill Clinton.

Near misses? Lucky was the guy who got shot in the face at point blank (The Single Bullet Story). He had his mouth open so it went in one cheek (slightly subzygomatic) and out the other missing his teeth, but he turned his head and ducked, the bullet exited and hit his shoulder shattering the clavicle exiting near the scapula. Missed the subclavian vessels entirely. No pneumothorax. He got discharged from the ED after a few hours. Then there's also the guy who got shot in the ass during a drive-by gang shooting. The guy heard shots rang out, he ducked and started running. The bullet strucked him in the ass and exited…at the top of his scapula. All subcutaneous soft tissue injury! No retained bullet fragments. He, too, was discharged from the ED after a short period of observation. Lucky dog! Perhaps the luckiest of all was the guy who was shot in the chest but the bullet hit the rivet button of his jacket right over his sternum. All he had was a little bruise.

Oh, I could go on with this for days. However, the story that gross people out the most involved these 3 schizophrenic guys and their testicles (I saw each of them at different times during my career, BTW). All three guys had a problem with…excessive masturbation. All three guys thought that one of their testicle was "possessed" because it hung lower than the other and they couldn't stop masturbating because of it. One guy took a kitchen knife and lopped it of. He was brought in by ambulance in hemorrhagic shock. The second guy took a nail gun and nailed his possessed ball to a wooden plank. The third guy took a hypodermic needle and injected his scrotum with all sort of stuff, lime juice, orange juice, bleach, Mr. Clean, soap, tomato juice, etc…He walked into the ED with a trail of pus dripping on the floor. His had developed a huge abscess and his scrotum hung down to near his knees. Stunk up the whole ED, one of the nurses ran to the sink and hurled. Anatomy quiz: In over 85% of men, which testicle hangs lower, left or right? And why? Don't tell me the ol' "so they won't knock together" answer either. [I'll be expecting answers to this question~MA] I have many stories of miraculous saves but we'll save that for another day.

Q.5 You wrote "ER docs are easily expendable, and that's a fact, jack." Would you advise medical students against going into emergency medicine? Do you regret your years as an ER doc, or your decision to become a doctor?

A.5 ER docs are easily expendable, that's the truth. The law does not require residency training and board certification to work in the ED. To my knowledge no state medical board or governing body thus far has ever required residency training and ABEM certification to work as an EM physician. There are hoards of family doctors, internists, etc… who would jump at the opportunity and "whoring themselves" to work in the ED for lesser pay than a residency trained and board certified EM doc, and many are already doing it. A few of them (very few) are decent, but the majority of them are dangerous and completely inexperienced to handle the acuity. That has been my observation over the years and I'll just leave it at that. Plus, there are many mega-corporations out there (EmCare, for instance) willing to low-ball the contract bids against the private groups, mainly because they can afford to be self-insured. And most of these corporations have no qualms or problem at all with staffing the ED with unqualified, inexperienced and non-ABEM certified physicians either because they are cheaper.

Would I recommend medical students against going into Emergency Medicine? Mommas don't let your babies grow up to be…hospital based physicians! I say this because there is a complete lack of autonomy at the administrative level in EM. Two scenario exist, you are either an employee of the hospital, or you are part of a group that has a contract with the hospital. In both instances, you are at the mercy of the hospital administrators, as very few hospital contracts are longer than a year or two. So much for job security, heh? Contract renegotiations are almost always very contentious and frustrating as the administrators will do their very best to deny you the revenues that you deserve or play mind games with you by interviewing other groups and corporations bidding for the same contract. They will use all sorts of erroneous benchmarks, spurrious statistics, invalid data and flawed patient satisfaction survey scores to bullshit you. Here's the real scoop. The ER is a huge money drain on the hospitals because of paltry reimbursements (Remember, EMTALA is an unfunded mandate.) Thus, it is the aim of the hospital administrators to limit the loss as much as they can. Since they can't control the patient census, they'll go after the ED physician's reimbursements. Very, very, very few ED's are profitable for the hospitals. As a result you approach the bargaining table already in a hole. If a medical student can accept this downside of EM, then go for it.

Though I've always wondered what would happen had I stayed in engineering and not go to medical school, or stayed in neurosurgery and not switched to Emergency Medicine…I don't regret my decisions at all. I've taken care of tens of thousands of patients in my career. And every day at work, I'ved saved someone's life and made a difference. Not too many people can say the same about their job. I've saved countless of lives in my career, so no regrets. Absolutely not. It's a pretty awesome feeling to walk away from a successful case, whether it's a crash thoracotomy, chest tube for a tension pneumothorax, pericardialcentesis for a cardiac tamponade, defibrillation for a ventricular fibrillation, securing a difficult airway, or just as mundane as making a diagnosis of appendicitis or scarlet fever. Definitely, no regrets!

Q.6 I think I've been reading too many disillusioned ER Doc blogs. Time to have some fun. This is the Valentine's edition of Calendar Docs, so we need answers to some personal questions, maybe even some love questions. So, what do you like to do when the scrubs come off?

A.6 I have this wicked addiction to windsurfing and have been doing it since 1982. My garage is filled with windsurfing equipments. I own more sails, masts, booms, fins and boards than I do clothes. I started taking up kite surfing a few years ago, but haven't had much time to devote myself to it to be any good. I'm a great windsurfer, however. Damn good at it, I must brag. Duck jibe, laydown jibe, 360, spock, vulcan, heli-tack, you name it, I can do all the tricks. [I tried to find a half nekkid guy windsurfing, but had to settle for the above. ~ MA]

When there's no wind, I go running. Got a couple of marathon under my belt already. Finished the 2004 Boston Marathon under 4 hrs.

My oldest brother taught me how to play classical guitar when I was 7 so it's another passion of mine that I'm passing on to my son.

Q.7 Describe the worst date you ever went on.

A.7 My date wasn't the problem. It was the cop who pulled me over and had my car towed. Long story. But short version goes like this… Speed trap, cop said I was driving 55 in a 35 zone. No I wasn't, I was going 45. Yes you were. No I wasn't, she's my witness. You're still over the speed limit…Oh what do we have here, Ohio driver license, Texas tag, how long have you been living and working in Louisiana? Car towed. Whuh?? My date (now wife) and I had to walk 8 miles in the rain to the nearest gas station to call a cab. Lesson: don't argue with the cops in Louisiana. Just accept the ticket and go on your way. (BTW, I no longer live and work in Louisiana. That was many years ago. I did however, volunteer for 4 wks. during Hurricane Katrina. Went there with our ambulance crew.)

Q.8 How old were you when you lost your virginity? [It's the Valentine's Day edition, I'm allowed to ask nosy questions~MA]

A.8 I saved myself for marriage (my wife's reading this, ya know). Honest, my wife is the only person I've ever been with. Cross my heart, it's the truth. I met her in chemistry lab during freshman year of undergrad. We ended up being lab partners because we were both late and there was no one else to pair with. We've been together ever since. Fate. But as I recalled, it was she who asked me, "You wanna be partner?" But she said otherwise.

My wife is the only person I've ever dated. I got it right the first time around. But we didn't get married until 12 yrs later. She went to grad school to pursue her PhD, then I went to med school, then residency...We stayed together through it all. When I was in high school, I was too busy working my ass off to help out my parents and family. My family fell on hard times and we ended up in the housing projects. Those were rough years but wouldn't trade them and the lessons learned for any gold in the world. Kinda hard to go on dates when you're still riding a bike and working your ass off every night. Plus, deep down inside, I was always consciously aware and somewhat too embarrassed about my family's poverty to ask any girl out on a date.

Q.9 Name five bloggers you would like to have dinner with.

A.9 You, of course! (Note: always play suck up to the interviewer) As for the others, the real question is, would they have dinner with me?

Q.10 If you won the lottery, what would be the first thing you'd buy?

A.10 Depends on how much the jackpot is! Probably some equipments for my free clinic. Xray machine, U/S machine, lab equipments etc… I would love to be able to do some labs/blood works and xrays in my clinic. Dang, if it's the lottery, how about a 64 slice CT scanner! I have a radiologist brother who's willing to read the films pro-bono over the internet.

Q.11 Well, we know about fingers and tubes. Tell us the most unusual thing you have removed from each orifice.

Ears – tooth, maggots
Nose – hookworm
Mouth/throat – Sandspur stuck at vocal cord
Urethra/Penile – Electrical wire (see my blog, the guy actually had to go to the OR)
Vaginal – bullets (.45 caliber), Scope bottle cap, seashells, crack pipes, drugs, pill bottles
Rectal – door knob, flash light, etc...The largest object, however, was a ceramic flower vase. Huge one, too. Still leaves me wondering…how?. You've seen the xrays of the beer bottle I sent ya, this was several times larger. It was humongous, monstrous, even. OMG, I'm still wondering… how?

Q.12 Quickfire Questions:
Favorite movie? Kingpin with Woody Harrelson and Randy Quaid (don't ask me why)
Favorite book? Sans Famille by Hector Malot (French novel), highly recommended
Favorite drink? Ice latté
Favorite meal? Anything Cajun
Any tattoos or piercings? Nope, unblemished as the day I was born.
Any pets? Got some gold fish (orandas and lionheads), do they count?
Any kids? Son 7, Daughter 5, Daughter 2
Any heroes? My father.
Guilty pleasure?
TV shows: Ninja Warrior
Junk food: Jalapeno Cheetos, Chili dogs, long trips to New Orleans just for Begnets and Café du Monde

Q.13 In your first post on FATIEO, you wrote:

I want to find joy in medicine once again. I never want to refer to it as a job. Things usually cease to be satisfying once it becomes a job. Burned out? I hope not. I hope that I never stop seeing the practice of medicine as a privilege entrusted to me by patients and their family members. It is my sincere desire that this sojourn into the blog space can somehow help me find that enthusiasm that I once had in medicine.

Do you consider your sojourn into the blogosphere a success, i.e., did you accomplish what you set out to do by blogging?

A.13 When I left the ED of "Crack City", I felt that a chapter in my life had closed and there was nothing interesting left to blog about. A case of congestive blog failure, you might say. However, I did find myself, and medicine is once again a privileged joy. The free clinic is quite busy since I'm doing everything by myself on most days without nursing help. But folks are mighty appreciative for every little thing I do for them, even if it is just to make a phone call to Crack City ER telling the staff that I'm sending someone who's got a more emergent and acute problem than what I can offer to help them in my li'l rinky dink clinic.. Not soon after opening up the clinic, which I affectionately named The Fistula (after a legendary landmark at the place I trained at), I had a moment of self-discovery that all along, this was something that I had yearned for, just a little bit of recognition and appreciation, an arm around the shoulder, a firm handshake and the words "thanks, doc." I never needed a big paycheck.

Q. 14 You were on one of those ER shows on the Discovery Health Channel. They still rerun some of the old shows. Can you give us a hint about which one is you? At least tell us what color scrubs to look for?

A.14 I think I was wearing green scrubs. I haven't seen those episodes in years. The only 2 scrub colors I had those days were green and blue. Wait, there's the off-gray scrub I stole from the VA Hospital.

[I recently learned that Dr. WhiteCoat was also on one of the Discovery ER shows! Hints. We need more hints. ~MA]

Q.15 Are you ever going to finish your story about how you got into medical school?

A.15 OK, I'll do it next week.

Thank you, Charity Doc. ~ MA

Thursday, February 14, 2008

Dr. February is . . . Charity Doc

Picture of "Serious" Charity Doc


Another one of my favorite ER docs. Charity Doc knows how to inform, educate and express his views in an entertaining way that even non-medical types like me can understand and enjoy. Who else would think of using a butt pus analogy when explaining how he would go about solving our health care crisis? [Note to self: consider adding "in ten words or less" to some of the calendar doc questions].

In Part Two, Charity answers some of my more juicier questions.

Here's Part One of my interview with Charity Doc:

Q.1 WTF? Where have you been? What are you doing? Are you coming back? Why did you leave us hanging like that? you get the idea...

I haven't left medicine at all, I'm still taking care of patients but in a much different capacity. I abandoned my old gig because had to practice medicine on my own terms. I desperately needed to eliminate all of the bullshit that had made me miserable as an ER doc. I had to do it without the fears of litigation. I had to do it without the guilt of streeting a patient because he/she does not have health insurance or cannot afford what needs to be done. I was sick and tired of arguing with consultants night in and night out about admitting a patient to the hospital only to have them refuse. Or after forcing them to admit, they then turn around to discharge the patient the very following morning. Here's one such scenario…There's this homeless lady who comes into to the ED all time with right upper quadrant abdominal pain. I performed a bedside ultrasound on her during one of the early visits and found her to have gallstones. I did the study informally (because we had an ultrasound machine in the ED) so that she wouldn't have to incur the charges of an ultrasound. She never paid any of her hospital bills anyway so that, too, is a pointless discussion. In all of her visits she would get lab'ed up every time and discharged home for outpatient follow up when her labs came back normal without elevated liver function tests or pancreatic enzymes or leukocytosis. Bottom line, this lady has chronic cholecystitis and needed to have her gallbladder resected, but no damn surgeon in town would do it for her for free. She shows up to the clinics for follow up but gets turned away at the front desk after a negative wallet biopsy each time. This is after me getting personal verbal reassurance numerous times from different surgeons over the phone that they will see her in clinic. Several times, I begged the hospitalists to admit her to the hospital and consult the surgeon on call, which they did as a favor to me. But then she got streeted the following day each time after getting "plugged in" with social services to procure fundings from local resources and agencies for her "elective" surgery. This funding never materialized so she's still out there, over a year now, suffering miserable pain and waiting for the day when she gets really sick with a fever and her labs coming back abnormal to show that she has gallstone pancreatitis, cholangitis, or a perforated gall bag. It's despicable!

I also despised the hospital administrators to no end. They have no clinical experience or background whatsoever (zero, zip, nil, nada!), yet they see it fit to dictate how I treat my patients by establishing all sorts of bullshit rules to impede what I do. One such glaring example was when they came down with this firm no diversion policy, yet won't allow me to use the hallways to put, see and treat patients in because "It's against JCAHO." So when the ED is filled to the gills with no empty beds, patients being boarded because there is no room upstairs, the waiting room/lobby is filled with triaged patients to be seen, ambulances keep calling in, surrounding Podunc hospitals on the phone requesting transfers, etc…what the hell is a frustrated ER doc to do? Pull a magic wand out of his ass? On top of that, hospital administrators have a very uncanny way of pissing off the nursing staff to make them quit. Every month, more and more experienced nurses leave to go elsewhere, and I'm left to deal with incompetent and inexperienced traveller nurses. Some of them are great, but the majority of them are horrible. Then there's the contentious issue of utilization reviews and patient satisfaction survey scores to piss me off even more. I've blogged about this ad nauseum already.

I had to get away. The ER had made me become an angry and suspicious doctor that I didn't like. I hated myself for seeing every patient as a potential lawsuit and hated myself even more for the cynicism and bitterness that now grappled me after over 20-something years of medicine. When you start referring to patients as trolls and squirrels, it's time to call it quits. I had to get away. I had to free my conscience and get back to the humanity of medicine. So, I opened my own free clinic using the available spaces provided by a local church. I see patients 3 days/wk. M, T, W 10a-1p, break for lunch, then 2p-5p. That's it. Very limitted funding from the local churches in the community. Quite busy though. The only folks helping are the local churches and a few local businesses, radio and TV stations. I couldn't get the local hospitals to donate anything. Nor could I get any local docs to volunteer their talents either. I did get a few nurses to volunteer, though. I suppose the hospitals see me as a competitor and business threat, which made little sense to me because while I was working in their ED's these patients weren't paying them a dime anyway. But, hey, I know the game, the county hospitals do get some fundings for providing indigent care. However, here's my point, there are plenty of poor and homeless folks out there to go around and if I can do my part to keep them from coming to the ED's for non-emergent problems, shouldn't that be the goal? This month, I'm running real low on disposable lac trays, 4x4's, iodoform packings, 1% Lidocaine, 11 blade scalpels, betadine, and sutures. Heck, I'm running low on everything and have already spent a hefty hunk of my own money to get this clinic up and running. I spend the majority of my clinic days I&D'ing CA-MRSA abscesses, suturing lacs, refilling meds (antihypertensive and oral hypoglycemics for the most part), and stomping out sorethroats, coughs, UTI's and STD's. Lord knows that homeless folks gets freaky, too! There are no diagnostic studies performed, I just treat them and street them. Thank Jesus for $4 meds at Walmart (matched by Target, CVS and the other local pharmacies). The drug reps help, too. I love it when they bring free lunch. I'm under no pressure to prescribe any of the meds that they peddled, of course, since my patients cannot afford them anyhow. As to the liability aspect of it all, I'm not sure and try to keep as detailed records of each encounter as I can. I'm just hoping that the Good Samaritan laws apply and have been wingin' it day by day. All patients must sign a liability waiver to be seen. I may have to cut down to 2 days a week because of lack of fundings. I moonlighted in a Podunc ER the other day after a friend begged me to help out. The stock market is tanking, I may have to go back working for real pay.

Q2. Tell us how you are going to spend Valentine's Day.

A.2 Having hot steamy sex with my wife, like always, of course.

Q.3 One of the presidential candidates has asked you for some advice on how to improve the nation's health care system. What do you tell them?

A.3 The health care crisis facing our country is akin to a festering butt pus in dire need of incision and drainage. Like butt pus, it's well covered up so no one else can see, but it sure hell is a huge pain in the ass! My long rant on the subject can be seen here.

To summarize, we have a real national crisis at hand and it seems that none of our politicians know how or even care to solve. When over 47 million Americans do not have health insurance, we have a big problem. When a person in America has to make a decision between food on the table or pills in a bottle to take for his/her medical problems, it is a national disgrace. When a man have to resort to committing a petty crime to land him in jail just so he can get the medical care that he couldn't otherwise afford, it is disturbing. When hospitals pass on the costs of healthcare to the public by marking everything up by 1000%, we all have to pay painfully. When doctors, who all took the Hippocratic Oath, are too fearful of litigation to take care of patients, order more unnecessary tests (shotgun CYA medicine), spread the liability by consulting other doctors and specialists to get everyone under the umbrella, or worse yet, abandon clinical privilege at a hospital so he wouldn't have to take care of unattached, nonpaying patients...the situation sucks all around. When hospital and HMO administrators without any clinical experience or medical background can dictate what tests and studies physicians can or cannot order, the ship is being run by idiots and is doom to sink. We're headed toward disaster, there's no doubt about it. This isn't all new. Everyone knows that this health care crisis exist but our nation choose to turn a blind eye. It is analogous to knowing that the levees in New Orleans cannot withold a hurricane for decades but we choose to ignore it all the same.

So how do we go about solving our health care crisis? Well, let's go back to the butt pus analogy. Taking care of butt pus ain't as easy as you think, but it ain't impossible. A clinician must first be able to see the bigger picture and look beyond the patient's ass. For instance, is this patient immunocompromised, is he a diabetic, etc…? Otherwise, just cuttin' and draining the abscess won't address the underlying disease. How did this butt pus come about? Is it an infected pilonidal cyst? MRSA? And before cutting on this butt pus, one must ask, is this a peri-anal or peri-rectal abscess? Is there a fistula? You get the point, there's more to butt pus than just the ass, or meets the eye. The problem with our politicians is that they cannot look beyond the ass and thus are oblivious to solving the problem.

From the patient's perspective, health care should be affordable, easily accessible, and without compromise to quality. From the provider's point of view, liability is the biggest issue, as well as autonomy, reimbursement and quality of family life. The buzzword that we often hear regarding health care reforms from our politicians lately is UNIVERSAL HEALTH CARE. Yes, indeed universal health care is a noble endeavor that we all should strive for in this country. But our politicians are approaching it all wrong, sliding into the direction of socializing health care. There is a HUGE difference between universal health care and socialized health care, but too many people mistake them for one and the same. They are not! It has been shown time and time again throughout history that whenever the government has absolute control, all things go to hell quickly in a handbasket. Our government cannot even keep its promise to provide health care to our veterans, what makes you think that Obama or Hillary can provide health care for every American in this country? With that said, however, we can have universal health care without socializing it. In fact, you might argue that we already have universal health care right now. The Federal EMTALA law (Emergency Medical Treatment and Active Labor Act) requires that every patient who shows up to a hospital ER must receive a medical screening and stabilization if that hospital participates in Medicare. Without Medicare funding, a hospital is certain to go belly up bankrupt and thus EMTALA is pretty much inclusive of all hospitals in the USA. Private clinics, however, are not bound by EMTALA to do the same. So in a way, we already have, sort of, universal health care here. The word is long out. If you have no health insurance and can't pay for health care, go to the nearest ER. You don't have to pay up front and we are too scare of law suits not to take care of you. You can make up phoney information about yourself, fake who you are, give 'em aliases, fake phone numbers and addresses, phoney social security numbers and you'll never have to see that hospital bill. Heck, all the homeless folks show up every night looking for a warm bed and free meal anyhow, in addition to free health care, of course. Two hots and a cot, as we call it. Now there's a novel idea! If you have a real medical problem that needs true emergent care, like an acute appendicitis or a hot gallbladder that needs to be operated on or something...pretend you're a homeless drunk, mess yourself up a little bit, wear dirty old clothes, not shave or shower, sprinkle a little beer on yourself for the smell...and if you want to really get into the role...piss in your pants for the stale urine up to the ER of a hospital they'll have to take care of you. You'll never see the hospital bill, guarantee it!!! The beauty is they will never come after you, not for collections, not even with a 20 ft pole, not ever! So there, you see, we already have universal health care in this country. Albeit twisted and somewhat sordid, but free/charity healthcare nonetheless. EMTALA is a well-intentioned law meant to prevent patient dumping and abandonment. Too many people, however, take advantage of it and abuse the system. In honesty though, we're not all heartless, money-grubbing bastards. We're here to help everyone who truly needs our expertise.

Oops, I got a little distracted. We can achieve universal health care coverage for everyone in this country without socializing it through government mandates. And we don't have to do it either by forcing everyone to buy health insurance policies that they can't afford. And we don't have to require all employers to provide health insurance coverage for their workers either, because small businesses would go belly up. How can we achieve such a gargantuan tasks? Too good to be true? Not really. Our health care crisis is multi-faceted and complex, and addressing only one aspect of it alone will not solve the problem. Putting a band-aid on a butt pus doesn't make it go away! Over the years, many have blamed the increasing costs of health care on the enormous jackpot awards of frivrolous lawsuits brought forth by greedy trial lawyers, like John Edwards. Many states have tried to solve that problem by capping non-punitive damages on malpractice suits, but guess what, the plaintiff attorneys just worked harder, bringing up more lawsuits in order to make up for loss revenues they once enjoyed. Did health care cost go down? Not really. Did it make health care more accessible? Nope. More Americans are uninsured than ever and ER census across the country continue to rise in reflection to those numbers. Are doctors still practicing defensive medicine and ordering unecessary tests? You betcha, even in Texas and Florida. So do groundless lawsuits drive up the cost of health care? It may have contributed some but isn't the only factor that has made things spiral out of control. Mitt Romney, to his credit, tried to solve the problem by a different approach while he was the governor of Massachusetts. His plan, mandating health insurance coverage across the board for every citizens, has proven to be too expensive, even for the rich state of Massachusetts to stomach. Government mandates have never worked, and never will. I can't imagine poor Mississippi or Louisiana being able to do the same when the wealthy folks of Massachusetts have failed so miserably. The benevolent aspirations of Mitt Romney were there, but the execution, was all wrong, and it wasn't just the mandates alone. Though the plan addressed the accessibility of health care, it failed to address the other problems. For true health care reform to work, every aspect of the problem needs to be addressed:

Patient's perspective:



Preservation of quality

Provider's perspective:




Let's break it all down.

A) Accesibility. Health care has to be easily accessible to all. For over 47 million Americans without insurance (and that number is projected to reach 50 million by the end of the decade), it ain't so accessible. In many cities, aside for the safety net of the ER, there is little to nowhere else for these folks to turn to. But it need not be that way. We already have the infrastructures at the local and state levels to increase health care access. I say expand our local Health Department system. Give the health departments a more clinical role rather than just being there to provide routine vaccinations and monitoring of infectious diseases. Doing so would, in essence, establish a national health care system to where people who cannot afford insurance or a private clinic can go to for routine primary care. This would serve the poorest and most impoverished segments of our society, in addition to providing care for those lazy asses who choose not to pay for themselves, the so called leeches. How do we fund this expansion? The states are already funded through medicaid. Right now, the states are allowed considerable flexibility on how to execute the program that costs over $300 Billions/yr. Anyone who has ever done a shift in the ER's knows full well how rampant Medicaid fraud and abuses are. Let's eliminate some of that flexibility and force the states to beef up their local health departments to a more clinical/primary care role. Give sovereign immunity to health care providers who are willing to take a pay cut to work in our health departments (more on liability issues later). You want free care? You can't eat your cake and have it too. Eliminate Medicaid and establish a national health care system through expansion of the health departments. Let the states run them, if they don't want to relinquish control. But Eliminate medicaid! The reimbursement for medicaid, as it exists, is paltry anyhow. Most private clinics refuse to accept medicaid anyway. They shun them like butt pus.

While we're at it, get rid of the federally funded State Children's Health Insurance Program (SCHIP), too. Here's the truth to the notion of providing umbrella health insurance coverage to every child in America, it's wasteful and fattens the wallets of the insurance carriers and HMO's more than it benefits us tax payers. While it's a noble endeavor, it's not cost effective. At first blush, it would seem to be a grandly benovelent idea to require health insurance across the board for all children. You can hear the outcries, can't ya? "But, but,'s for our babies! We are the wealthiest nation in the world...and we can't provide healthcare for our children?..." Problem is, SCHIP is a gargantuanly expensive endeavour that does not provide the biggest bang for the bucks and makes no economical sense. Fact is, the overwhelming majority of kids do not get severely sick and have no need for expansive health insurance coverage. Sure they'll get the routine common colds, snotty nose, cough, sore throat and the sniffles. But for the most part, the majority of kids are healthy and are not afflicted with serious illnesses. Therefore, mandating health insurance coverage across the board for every kid in America is wasteful and serves the health insurance industry more than it does the kids. As a physician, I would love nothing more than seeing a well insured kid for a routine viral snot nose and sniffle in my ER. Quick 5 minute exam...Easy Chaching! But as a responsible taxpayer I see it as nothing but wasteful drain on our collective wallets. Day after day on duty I see hoards of medicaid covered kids rushed to my ER, sometimes even by ambulance, for routine snot noses and sorethroats. Sadly less than 10% of all the kids I see in my ER have a true medical emergency. Medicaid abuse is sickeningly rampant. Fiscal discipline and responsibility is called for here and "it's for the kids" can no longer cut it as an excuse.

Instead, for kids and healthy young adults, a catastrophic insurance policy makes more sense and is more cost effective, because these policies are much cheaper and are applicable in instances of unexpected calamity such as injuries after a motor vehicle accident, sudden illnesses requiring extensive/prolonged healthcare (meninigitis, appendicitis, new onset diabetes, broken bones ect...).

Abolish Medicaid and SCHIP! Use that $300+ Billions to establish a national health care system through expansion of the existing health departments. To get the manpower for the national health care system, give student loans breaks to physicians, PA's, ARNP's, RN's, LPN's, etc…who are willing to work for the health departments. Recruit students through scholarship offers to work in the health departments once they're done. 4 yrs of med school for 4 yrs of indentured servitude in the national health care system is a very fair deal, much like the military's GI Bill.

B) Affordability. Unless your portfolio rivals that of Bill Gates, Warren Buffet and the likes, for most Americans, myself included, we are all just one medical disaster away from bankruptcy, insured or not. Imagine a serious car accident, or heaven forbids, a diagnosis of some malignant cancer. If you're uninsured and play by the rule, you're screwed. If you are insured and think that your HMO will be there for you, you're naïve. ~$5,000 per day in the ICU ain't no chump change! The spiraling costs of health care just boggles the mind. By 2012, health care expenditures are expected to be about 17-20% of the GDP. A routine visit for an ankle sprain with a simple ankle series xrays used to cost $40 bucks when I first started medical school, now it costs $240 bucks! That's just the charges for the xrays alone, not for the visit, splints, crutches, nor is radiologist's charges for reading the films included.

There is a 1000% mark up for every thing as soon as you step through the door of the hospital. That's right ONE THOUSAND PERCENT mark up, not including physician fees, just hospital charges alone. One could argue that the $6 Tylenol pill is also paying for the heating and air conditioning, lights, utilities, house keeping, grounds maintenance, etc… But c'mon 1000%? Ain't that a little too obscene?

We've already established that socializing health care through gov't mandates does not work. It never has, but creating a national health care system as discussed above is absolutely necessary and would certainly increase primary care access for the extremely impoverished segments of our society who could not otherwise afford it. And for children and young healthy adults, a catastrophic insurance plan makes more economical sense as such policies are much cheaper. But what about the rest of us who plays by the rules and see government handouts as un-American and an insult to the very foundation of our democracy, self-reliance and individualism? How can we make health insurance more affordable for people who wants to take care of themselves and not rely on the gub'mint?

One of the main problem of our health care system is that there is no true competition. By that, I mean that there is an absolute lack of capitalism in health care. The spirit of capitalism is what made this country great, yet it is completely absent and devoid in the health care industry. From DRG fixed pricing through ICD codings established by Medicare, to the limitting and confining of insurance purchases within certain regions and state lines, capitalism does not exist in health care at all! And as a direct result, prices soar out of control to no end. To fix this problem we need to inject capitalism into health care and let the basic principles of supply and demand in economics take care of itself. Laissez-faire and let the market forces work! Let all of the hospitals and clinics compete. Let them set their own prices to drive down market costs. If at hospital A, I can get a hip replacement cheaper than at hospital B, transfer me to hospital A…If at the neighborhood clinic a routine visit is cheaper than at uptown clinic….you get the point. In the same vein, let all of the insurance companies compete across state lines. Allow small business, citizens of cities, towns, municipalities, etc…to band together for purchasing power to leverage for a cheaper price with insurance companies, much like the deals that large corporations can cut with these insurance companies.

The answer to our health care crisis is not to socialize it but to inject capitalism into it. Free enterprise! Let the market work!

C) Preservation of Quality. It is without question that we have the most technologically advance health care system that is the envy of the word. As it should be, because Americans demand no less. Any discussion in the overhauling of health care must include the preservation of quality that we currently have. Our health care providers must pass stringent criterias including appropriate trainings and board certifications. That cannot change as public confidence, not to mention safety, in our profession is of utmost importance.

D) Liability, Autonomy, Reimbursements, and Quality of family life (The physician side of the story). I would like to lump all of this into one discussion from a physician perspective, as these issues are all dynamically related and intertwined. As a physician who has been frivolously sued numerous times, I can personally attest that each case was equally gut wrenching and ripped me to the core. It was one of the major factor that weighed heavily and contributed to my decision to leave Emergency Medicine. Yes, every single one of those cases were completely meritless but they still haunted my psyche all the same. I hated to practice defensive CYA medicine. I hated myself for seeing every patient encounter as a potential lawsuit. Do groundless junk lawsuits drive up the cost of health care? Not entirely as recent studies dispute such argument that frivolous claims are the largest contributor to our health care problem. But one thing is clear, these junk suits certainly do contribute to the pie of discontentment making all physicians miserable. On top of that liability insurance costs are insanely astronomical. In my group of physicians covering an ED of 78,000 patients/yr. census, it costs us $1.2Million/yr in liability coverage. And that's cheap compared to other groups of comparable census in other states. Patients and their family bring suit, for the most part, due to bad outcomes. However, recent studies have shown that nearly 80% of all claims did not involve errors and did not receive compensation. So why the hell are the rest of us paying so much for liability insurance to the point that it cripples our business?

Escalating matters in our current health care environment is that more and more Americans are uninsured and the numbers are expected to continue to rise. And where do they go for their health care? They show up to the ER's across the country, of course, bogging down the system causing a serious overcrowding. Why do they not show up to the local clinics for routine nonemergent stuff? Well, that's because the clinics will first do a wallet biopsy as soon as patients show up at their reception desks. Thus, uninsured patients show up in hoards to the ERs because we don't and cannot make them pay first to be seen. That's the problem, EMTALA IS AN UNFUNDED MANDATE! I talk about the ER mainly because it is my field of expertise. But more importantly, I bring up this issue because unattached ER coverage is the single greatest cause of malcontent among the hospital staff of all specialties and subspecialties. As the growing numbers of uninsured patients continue to rise, compounded by the flood of illegal aliens, the safety net of the ER is the only place that these patients can turn to. At the hospital where I had been, our census doubled over a short period of 3 years. However, our ER reimbursement rate dropped to 27%. That means only 3 out of every 10 bills we send out get paid. About 3 out of every 10 patients we see actually pay us! Can you imagine any other business being able to survive on such piss poor returns? Just how do we survive and maintain our practice? The hospital has to kick in a subsidy, of course. But it's no where near enough for us to hire adequate staffing to be able to efficiently handle the patient load. The hospital in turn gets funding from the federal and state and local levels. What's more, the current nation wide nursing shortage bottlenecks our situation to a grinding halt on many nights. Not only are there not enough ER nurses, there aren't enough floor and ICU nurses as well. The facility actually has plenty of beds, just not enough nurses upstairs to take care of patients so they get boarded in the ER until one becomes available. Meanwhile, patients keep on showing up with no rooms to put them into. We triage and care for the sickest ones first, of course, and do the best we can. An average of 4-5 hours waiting time for nonemergent cases such as sorethroats, runny noses, toothaches not uncommon at all....which all equate to crappy Press-Ganey patient satisfaction scores and lower incentive driven reimbursements and bonuses for grunts like me. Damn vicious cycle and ploy isn't it.

The problem with uninsured patients is just not the financial aspect alone. Uninsured patients usually do not have a primary care physician. Because of such, many of them have not had any routine maintenance or preventive health care and have neglected themselves for years. They tend to be noncompliant with medical management when they do show up. It's pretty hard to be compliant, though, when you can't afford things such as medicaltions. Thus, it is of no surprise that the uninsured patient will usually have more complex medical problems and more comorbidities. From the consultants' side of the story, the longstanding rule is that for a physician to have practicing privilege at a hospital, he/she must agree to take unattached inpatient and ER calls. Now if you are a specialist or surgeon, why would you want to take call at a busy county hospital that requires you to see more patients, who are sicker, who don't pay, have more medical problems that are more complex with higher comorbidity and thus, higher liability? Yes, these are precisely the patient demographics that sue most often. Taking call at a hospital means that you'll have to work longer hours, see your family less, take care of more patients, with higher acuity, more complex comorbidities, who are likely to sue you more...and finally the kicker...not get paid for it. Furthermore, having to care for these unattached, nonpaying patients disrupts the physicians' private practice and detracts time away from their own paying clinic patients. As a result of this, outpatient surgical centers are popping up everywhere across the country. These centers allows a surgeon/specialist to maintain his/her clinic and paying customer base while not having to take on unattached ER and hospital calls. Likewise for this reason, many internists, family practicioners, and pediatricians have given up their hospital privilege and just maintain a clinic. I can't say that I blame them. Many factors play into why physicians abandon hospital privileges, but bottom line, higher census, lower reimbursement, higher liability are all major factors. And quality of life kinda sucks when you're spending more time at the hospital than with your own family.

To answer for fewer doctors wanting to take unattached calls, many hospitals have started IMS (inpatient medicine service) programs and are paying physicians to work as Hospitalists. Once the hospitals started paying the internists to take unattached calls, they opened a can of worms, as all of the surgeons and all the subspecialists soon started demanding compensation for taking unattached calls as well. With low reimbursement, limitted fundings, and all the specialties wanting a piece of the small pie, hospital administrators are faced with tough decisions as they cannot afford to pay everyone.

Such are the realities of modern medicine. So how can we fix this mess? What incentives can we offer to health care providers, physicians, esp. the subspecialists, to retain them at the hospitals and take care of patients? It is my personal faith in the altruism of my colleagues that I say I doubt there are that many physicians so cold-hearted to the point of refusing emergent care of a patient based on inability to pay. I personally believe the ones who do are very few and far in between. Admittedly however, this broken health care system does grind us all down and has undeniably made cynics out of us all, unfortunately. But I refuse to believe that those of us in medicine, entrusted to care for our fellow man, someone's father, mother, brothers, sisters, sons & daughters… have abandoned humanity altogether. The root cause for such discontent in the medical community regarding unattached calls is the fact that EMTALA IS AN UNFUNDED MANDATE. But as I said earlier, I don't think that any physician would deny emergent care to a patient based on inability to pay. What's frustating about EMTALA, though, is that it's a one way street that does not provide the physician any liability protection after being forced by federal laws to care for a patient with whom he/she does not have any established relationship with. Not getting pay for it is just adding salt into the wound. And the final thrust of the knife is the disruption of the physician's office practice by taking away the time the physician could have spent with his/her paying private patients. It's a triple whammy that leaves no incentive for the doctor to take call at a hospital at all. There will always be indigent patients, that's a given. But let's level the playing field. If physicians are forced to emergently care for patients with whom they have no prior established relationship with, then let's make it a little fairer by allowing sovereign immunity for EMTALA care. Let the physician practice medicine the way that it ought to be without the fear of litigation. Let the physician use his/her clinical skills and intuition instead of ordering unecessary tests out of fear of a lawsuit. That certainly would help cut the costs health care. Or at least establish a medical court to where physicians will be judged by a jury of their true peers rather than by an easily persuaded sympathetic jury. Let's face it, expert witnesses are a dime a dozen and both sides can pay a so claimed "expert" to say whatever each wants. I'm too familiar with this game after being embroiled in numerous groundless, frivolous lawsuits. Sovereign immunity for EMTALA care would be ideal, but let's be truthful, there are plenty of incompetent quacks out there who should have never been given a license to practice in the first place. Let's restore justice and establish a medical court system. You have patent courts, why can't you have medical courts? Surely you cannot expect Joe/Jane Average to be a fully knowledgeable and informed peer of a physician who spent well over 12+ years of higher education and training to hone his/her craft? It's only fair that we establish a medical court wherein a physician may be judged by an impartial and qualified jury comprised of not only respected physicians in the specialty pertinent to the case but also patient advocates who actually have a clinical background. If you think that physicians would be reluctant to punish another physician then you haven't obviously been to any hospital Morbidity and Mortality Conferences, esp. the ones held by the Dept. of Surgery. Those folks are brutal to each other.

Lastly, the lack of reimbursement for EMTALA care must be offset for the time spent. As has been displayed by the State of Massachusetts, mandating health insurance coverage for every citizen is unfeasible as it is too costly. But for physicians willing to take on unattached calls, not getting paid for the work and on top of that, a double whammy to the books from time detracted away from paying clinic patients hurt. This is essentially charity work so for fairness sakes, allow physicians to deduct non-reimbursed EMTALA care from their taxes. If you donate money or items to charity, you can deduct it from your taxes. This is no different. If you want us to provide charity/free care to the public, at least allow us to deduct a percentage of it off our taxes so it wouldn't cripple the operation of our clinics because when we're spending time to take care of uninsured patients, it is time taken away from our paying patients.

There you have it, those are my suggestions for overhauling our health care system. Make it accessible, esp. to those who can't afford it, by eliminating the inefficient and wasteful Medicaid and SCHIP programs to establish a national health care system through the expansion of the existing health department system. Make it more affordable by injecting capitalism into health care to allow hospitals, clinics and insurance companies to compete among each other. Ensure quality and patient safety. And lastly for health care providers, establish a medical court and level the playing field for EMTALA care.
Thank you Charity Doc for being Dr. February.

Monday, February 11, 2008

Saturday, February 09, 2008

Post No. 200

Blogger says this is my 200th post. Something tells me Blogger is including the 99 posts that I deleted before anyone could read them. Thanks for continuing to stop by.

Okay, I can't stop playing with it. Thank you for your comments. It's called Toondoo. Here's the link.

Wednesday, February 06, 2008

Running with the Big Dogs . . . Not

Healthcare 100

A couple of days ago, I began to notice that in addition to my usual 15 (loyal, faithful) readers, I was getting 2-3 visitors from the Healthcare100 site. That was unusual, so I went on over there to check things out. I thought maybe they had a Bottom Dweller of The Week spot, and it was ATM's week.

Well, it turns out that a mistake has been made somewhere, probably Technorati, and ATM is now ranked Number 47.

So, welcome Healthcare100 visitors, if you are looking for a real top 50 medblog, take a look at my blogroll.

(I apologize to the real Number 47; I'm sure that the error will be corrected soon and all with be right with the blogosphere again. And thank you Healthcare100 for the listing, top 50 or top 500.)

**Calendar Watchers -- my ass has been getting whipped at work and I haven't had time to even come up with some questions (yes, I spend more than 15 minutes on the questions, smartass. I told y'all it takes me longer to come up with the questions than it does for the doctor to come up with the witty and amusing answers.) But it's a very special Valentine's edition, so it is worth the wait.