Just a Few Quick Things

Baby Jail

Remember how I told you that residents are underpaid for the work they do and how we are worth a lot more to the hospital than the monthly reimbursement the hospital gets from Medicare?

Well, like most things there are exceptions and I am living that exception this month as I lollygag my way through two weeks of purgatory (for an Emergency Medicine resident anyways) in a little place called Baby Jail, otherwise known as the Regional Neonatal Intensive Care Unit. To say I do nothing and am responsible for nothing would be an understatement. It’s not even as if I could take charge and a make a great contribution if I wanted to (which I don’t) because the most excellent nurses, nurse practioners, pediatric residents, neonatology fellows, and neonatologists have that place sewn up tight. They assign me a couple of babies but it’s nothing like the adult ICU where my program’s residents run the place for the attendings and nobody actually lets me manage my babies (and I don’t want to either). As far as I’m concerned, this should be an observational rotation.

I have the greatest respect for neonatologists. The ones here are excellent and I truly believe they are doing the Lord’s work, giving every baby possible a chance at life. I may be a cynic when it comes to end-of-life care for the warm dead in the adult ICU but this cynicism does not extend to the NICU where even babies born as early as 24 weeks can sometimes (sometimes, dammit) survive and blossom as children. Still, it is decidely a low-yield rotation for us. I don’t think I’m ever going to be calculating the caloric requirements and mix of proteins and fats for a preemie. If I ever get one I’m going to slap that kid on some D10 like it says on my pocket card and get him to the nearest NICU so fast that the malpractice lawyers swarming the poor OB who delivered the baby will say, “Damn, that guy is fast.”

So every day is, if not completely unpleasant, a kind of slow torture as I follow along on rounds knowing that they know that I know that they know that I’m not really interested and am counting the days until I can do something, anything, else. I am trying to get as many lumbar punctures and other procedures as I can but that’s about the only use of the rotation. I did a month of newborn nursery last year so I know how to get the Ballard score on a baby and meaning of various hip clicks and clunks.

Please, spare me the usual rah-rah pep talk about how I need to make my job relevant and make myself useful to the attendings. The consensus of every one of our residents who have done the rotation is that residents and fellows here are great people, the work is vitally important (perhaps the most important in the whole joint) but our presence is both puzzling and useless. Some of your rotations as a resident are going to be like that. You will finally get to the point where you understand that you are covering ground over which you will never tread again.

Q24H

Mrs. Panda has taken the cubs to Florida for a week so I have had a little extra time to work on articles. It’s either that or just stare at the dogs and try to fathom their canine minds. I’ve got five of them and they’re sprawled despondantly around me waiting for the alpha female to return. The point is that I try to make all my posts about something and not just write a blurb here or there. I think even my critics will agree that this blog has a lot of content.

However, writing takes a lot out of me especially on a call-heavy month. But I plug away at it and appreciate you folks taking the time to read what I have to write. I realize some of you are clicking over here every day looking for some interesting commentary and if I could, I’d write a long article every day but I can’t. So I’ve started a page called Q24H where I’ll post brief comments, interesting (hopefully) observations, and maybe some ideas that I might later flesh out into posts. If any of you would like to contribute articles email them to me and I’ll consider putting them up. You could just post them in the comments section of an article but I think more people will read them if I post them on the Q24H page.

As usual, spelling, grammar, and voice are important. No rants, either and if I don’t use them I won’t use them but I will give you full credit when I do. Comments are not allowed in the Q24H section. It’s the “take it or leave it” page.

Comments

I think we have done a marvelous job of keeping the debate civil. I could use a little less condescension from Matthew but if that’s his style, well, it’s his style. But I am going to call him out on it. I will say that he is a policy wonk and therefore, because he understands the complexity of policy he believes that he knows more than he does. I am not a policy wonk but I understand economics and know full well that twenty years from now after almost two decades of Single Payer health care Matthew will still be wonking and still looking for somebody to blame because our people will still be unhealthy as all get out, he has to wait on grimy plastic chairs with everybody else, and the costs of his money-saving idea have ballooned to the point where nobody even remembers the good old days when we paid for our own health insurance and, in retrospect, it was pretty inexpensive.

Just a Few Quick Things

Single Payer Dreaming

(The third time’s a charm as they say. Again, from the tone of many of my emails, not all of them as polite as you would imagine coming as they do from people who make it their business to be compassionate, I can see that many of you are still not getting it. Let us try one more time to show those of you who worship at the altar of public policy, any public policy, that your gods are mererly hollow brass castings which, although they make mystical noises when the wind blows a certain way, are as empty as a French Army recruiting office after the Germans have invaded.-PB)

Potemkin Health Care

Before the United States can have anything approaching the obvious perfection of European-style universal health care, our people are going to have to learn some good manners. While I am a fierce patriot and love America before all other countries, I cannot help but to admire the urbanity and the insouciance with which Europeans obligingly die before they can become a burden to their nanny states.

In truth, I am ashamed to report that where Americans, in a typically boorish fashion, will insist on hundreds of thousands of dollars of medical care to preserve their shameless lives beyond the point where it would be convenient for society, in Europe not only are many procedures and medications unavailable to patients over a certain age but some of those elegant continentals have even hit on the money-saving idea of offering a couple of hundred guilders worth of euthanasia drugs to politely eliminate those who might otherwise become a burden.

The problem with offering universal access to health care, which should be obvious to anyone with good manners, is that there is an almost inexhaustible demand for it. Maybe you, oh loyal and patient reader, don’t think about this as you are no doubt a veritable Hector or Andromache, in the prime of your life and about to conquer the medical world, but the old and the infirm, with stunning bad manners, do want their hips replaced, their coronary arteries vigorously scrubbed, and their expensive sojourns in the intensive care unit. Sadly, there is no end to their demands as they clamour for more and more precious health care, grimly hanging on just for spite until at around 90, eighty if we’re lucky, their bad manners finally catch up to them like their mothers from the turn of the last century said they would.

It’s shameful. The demand may be inexhaustible but the supply cannot possible keep pace. Certainly not now where, with typical American insensivity, we structure our society around merit and allocate services to those who earn them and certainly not under a single payer system where there is no restraint on demand whatsoever…except that it is to be hoped we learn some European style-good manners.

And quickly, too, because lurking in the demographic shadows is a huge bolus of rapidly aging baby-boomers, perhaps the most self-centered generation our country has ever produced, and they, of all people, will not go quietly into that good night…at least not unless shuffling off of your mortal coil becomes a hip-and-trendy lifestyle choice. It will be the largest eat-and-run the nation has ever seen and somebody is going to have to pick up the tab.

So, it may come to pass that our country adopts a single payer system in our impossible quest to provide high quality health care for all. The result will be pretty much what anybody who thinks about it could predict. We will have a lovely little health care system that looks nice, sounds nice, and finally wins us the adulation of our charming European friends that many of us so ferverently desire. But please don’t have the bad manners, the unmitigated gall, to get sick and require anything that can’t be provided at a simple visit to your barefoot doctor. You will find your marvelous access is nothing more than a creaky rationing scheme and your shining medical city on a hill is really a Potemkin Village.

Single Payer Dreaming

Single Payer Monte

(Judging from my email, the previous article was poorly understood even though I tried to break things down to the most fundamental level possible. I used little, easy-to-read words and I even made mention of dogs biting scrotums for crying out loud. Let me take another crack at it for the sake of those of you who need to have things explained a few times. -PB)

Universal Access, Tatooed Ladies, and the Dreaded “R” Word

Let us consider how the typical uninsured patient accesses health care. Arriving at the Emergency Department after a brief stop at the tatoo parlor for the finishing touches on a modest tiger motif around her left breast, our patient stubs out her cigarette, throws the scanty remains of her super-sized Big Mac meal into a nearby trash can, and with her three disheveled children in tow waddles to the triage desk where she presents for some common complication of her smoking and her non-insulin dependent diabetes. After a brief assessment by the triage nurse, she is directed to a row of grimy plastic chairs where she and her three children, Kristal, Alexa, and Deshawn will spend the next six hours watching The Fresh Prince of Bel Air while eating stale chips from the vending machines.

While there is no shortage of health care in our patient’s city it is still, like every other good or service, scarce meaning that there is not enough of it to completely meet the demand at the price that people are willing to pay. In our patient’s case, she is unwilling (and unable) to pay anything at all for this scarce service. From her perspective, health care is tightly rationed and although she is going to eventually receive top-notch care, she will end up spending eight good hours (at least) of otherwise productive time essentially standing in line for a few minutes of the Emergency Physician’s time. That’s how the poor pay for their rationed health care, with time and inconvenience.

The key concept to keep in the back of your mind (with the scrotum biting dog) is that every good or service is rationed in some way or another. In a free market system, it is the invisible hand of the market, the collective wisdom of millions of buyers and sellers deciding what something is worth, that sets the price and determines access. If you have, for example, the money for insurance and your copay you can generally make an appointment with your doctor and avoid the plastic chairs and stale chips. We also, however, live in a society that provides government funded charity as our finer impulses compel us to provide medical care (along with other goods and services) to the poor. But as this kind of charity work doesn’t pay very well, with the exception of a zealot or two the enthusiasm to provide it is not strong.

Which explains the plastic chairs, the chips, and the wait.

Now imagine our tatooed lady along with every other uninsured person in the United States waking up to find themselves the beneficiaries of a health insurance policy paid for by Uncle “Single Payer” Sam. A year later and they will still be sitting in the same plastic chairs in the Emergency department because the government cannot provide access to additional services that don’t exist. Unfortunately, not only does a single payer system do nothing to increase the supply of the service it purports to provide but the benevolant teeth of the government dog biting the important parts (the money, for those of you not following along) will limit the financial incentive to produce more of the service.

In a rational system, an increase in demand would be met by an increase in production (spurred by an increase in price) to meet the demand. The production of health care, however, is relatively inelastic. Doctors, midlevels, and nurses can only see so many patients. I don’t know too many doctors, for instance, who have a shortage of patients. To the contrary, the number one complaint of most health care providors is the need to run patients in and out like cattle to make a living.

There is a some elasticity in supply but not much. For the right price, most health care providers will see more patients, the key being that the incentive to stay at the clinic another three hours or work on Saturday has to outweigh the desire for leisure. Still, as it takes a minimum of seven years to train a doctor, three to train a Physician Assistant and somewhere in between for a nurse practioner, unless we want to have motivated junior college graduates as primary care providers the ability to increase the production of health care will always be limited.

Unfortunately, when the government controls the price of anything for which it must pay, the overwhelming tendency is to decrease the price even at a time when to meet increased demand the correct play is to increase the price to encourage the producers. Money itself is a scarce resource to a government and must also be rationed, usually in a way that panders to one constituency or another. (Governments cannot create money, although some have tried with disasterous economic consequences.)

In the quasi-single payer system of Medicaid and Medicare we have today, the goverment fixes the price at such a low level that those who decide to let the dog into their practice have to run a high volume business. If the last vestige of restraint was removed from the government to at least pretend to meet a reasonable market price, the bid price for health care would fall so low that any available excess production capacity would be held back from the market in the ancient tradition of all producers in the face of price fixing, to be sold for the real price to those who can afford it. In this case this would be the same people who have health insurance now, except in a Single Payer world this would be through supplemental insurance or its functional equivalent. That is until the government that promised not to get involved in any other way but providing insurance outlaws this practice.

Does our tatooed patient care about any of this? Probably not. She doesn’t pay a dime now. She won’t pay a dime in the future. The care will still be rationed and she will still sit on plastic chairs waiting…except now she’ll have a lot more company.

Single Payer Monte

Single Payer Shell Game

The Bureaucracy That Dare Not Speak Its Name

To hear its proponents describe it, under a Single Payer system of national health care the government wouldn’t even be involved. Apparently, even though such a system designates the government as the eponymous Single Payer who would pay everybody’s health care costs from tax revenues, the private sector will still be fully in charge as the government will neither run the hospitals nor employ doctors as they do in those creaky, decaying socialist countries. In fact, the hand of the government would be as soft as the milky fingers of a sixteen-year-old Lithuanian Virgin on her wedding night.

You’ll hardly notice.

Now look, I don’t have a degree in economics and I don’t belong to a think tank where I am paid to shill my particular brand of public policy. On the other hand, I have a little common sense and have kept my eyes open.

If you were to get in a scrap with a mean old junkyard dog and he managed to sink his teeth into your scrotum, from that point forward the dog is totally in charge. You may have the complete use of the rest of your body and even though, from a real estate point of view, the dog has laid claim to a fairly small portion of your property, where that dog goes you will go and you heart, mind, and soul will follow willingly.

Money drives medicine. Not a nurse empties a bed pan nor a surgeon repairs a hernia without money changing hands. This is so obvious that it is almost insulting to mention it. And yet the proponents of a Single Payer system seem to believe that, although the government would have its teeth firmly embedded where it counts in every medical decision, nothing but good could possibly result. It seems, at last, that our ruling elites have devised a system of total control which is appealing enough to convince the ignoratti but from which no blame could ever be extrapolated to government (who don’t actually run the hospitals or employ doctors, you see) when things go south which they inevitably will.

South they will go because the premises of socialized medicine (which is what a Single Payer system is except for a minor technicality) are all wrong and will do nothing to correct any of the perceived problems of health care delivery, most of which are overblown anyways.

First of all, price fixing always leads to scarcity as there has never been a government in the history of the world that fixed the price of a good or service above or even close to the market price. If you don’t think this is true, ask yourself why so many doctors refuse to take Medicaid patients. The answer is simple; because the real cost to treat a Medicaid patient is often more than the government’s fixed price. In a Single Payer system, the government might not own the insurance company but this is about as relevant as the government’s non-ownership of hospitals or non-employment of doctors. Under the Axiom of the Junkyard Dog, the government has the important parts (the funds) clamped in its jaws and it can dictate terms to the insurance company (what they can charge) and the health care provider (what they can bill). Because money is also a scarce resource, the pressure on reimbursement will always be down with nothing to resist it. Certainly not any pressure from the electorate, most of whom want a free lunch no matter how much it actually costs them and who are pandered to shamelessly on a regular schedule of elections.

Decreasing reimbursements would be fine to the ignoratti, of course, as those rich doctors and capitalist-tool insurance executives would finally get their comeuppances but if you think it is hard to get an appointment with your doctor now, wait until your doctor’s economic incentive is completely removed and see how the system which currently can get a wino to the cath lab in about an hour and a half would slow to a crawl. This would be because a Single Payer system increase demand, as people will take more of anything if it is cheap or even free, without doing anything to address supply. In fact, the decreased reimbursements to health care providers that would certainly ensue as the dog ground its teeth would decrease supply at the time demand was increasing.

Does our country even need universal health insurance and will adopting it make us healthier and decrease expenditures for medical care?

No and no.

First of all, nobody is exactly clear on the number of uninsured, who they are, and the significance their lack of health insurance. Forty million is a number thrown around a lot but as most of the elderly are covered under Medicare, all poor children and those from the lower middle-class are covered (or can be) under Medicaid’s Children’s Health Insurance Program, and many of the poor themselves get Medicaid, the forty million includes a fair portion of people who make the choice not to buy health insurance, either because they don’t need it or because they make a rational decision to spend the money on something else.

As we are a charitable people and it would be demoralizing to our society to have people dying for lack of medical attention, we need to have the so-called safety net to take care of people who simply cannot, through some combination of bad luck and personal choices, take care of themselves. But what if this number is only 10 million, not forty? Rather than have the government suck up even more money for redistribution in a highly inefficient, wasteful, and nonproductive manner, why don’t we just identify the 10 million hard-core uninsured and give them all health insurance with no strings attached. Seems to me that this would be several orders of magnitude cheaper than running what amounts to fifteen percent of our GDP through the Federal sausage stuffer.

There has, in fact, never been a government program whose costs have not risen well beyond even the wildest speculations of its critics and Single Payer would be no different, with its proponents 10 years from now opining that we have too many aircraft carriers and that the several trillion dollars spent on health care is not enough.

As to improving the health of the nation, well, I get attacked as a heretic for saying this but there is probably very little correlation between access to health care and health, especially as people who make health care a priority are the kind of people who would take care of themselves even if they didn’t have health insurance. Having a nice government health insurance policy will do absolutely nothing to get people to lose weight, stop smoking, exercise, and stop using crack, which, along with other poor lifestyle decisions are what really drives health care costs through the roof. This is readily apparent to anybody who works in a hospital. If it wasn’t for booze, cigarettes, drugs, 64-ounce Colas, Big Macs, and sedentary lifestyles, we would be all out of a job.

Single Payer Shell Game

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 7

Family Medicine

(Some medical schools have a formal Family Medicine rotation while others have a regular continuity clinic that runs concurrently with your other rotations in third and fourth year. Osteopathic medical schools hit Family Medicine and primary care like a pimp with his biaches, that is, hard and often.-PB)

Your Real Responsibilities:

Nothing.  You’re a medical student  You don’t count.  When you first get started your continuity patients who have at last found someone to listen to their long and incredibly boring back-pain epics will get the kind of rush that made them become professional patients in the first place.  So if you have any responsibility, it is to put the teeth into your school’s empathy indoctrination.  Relish this time because it may be the last chance you have to fritter away forty-five minutes exploring every detail of a patient’s life like your non-physician empathy instructors told you to do.

Your Pretend Responsibilities:

If you rotate on an inpatient Family Medicine service, it will be pretty much what you did on your Medicine rotation except the census will be smaller and your patients will generally not be as sick.  Traditionally, Family Medicine only admits their clinic patients, not everybody who shows up like Medicine, so while the service is small, usually consisting of an attending an intern, and an upper-level or two, the pool of potential patients is even smaller.  This will probably be a pretty relaxed rotation as you will not be seeing many patients.

In clinic, you will pretend to evaluate patients who you will present to your attendings.  Eventually your attendings might start to trust you with the minor stuff (and there is a lot of minor stuff) so you may run the whole encounter with a brief social visit by the attending to verify that it is indeed a post-nasal drip and not a raging esophageal cancer.

Things You Should Learn:

Three words: Routine Health Maintenance.

Learn when your patients are due for their shots, their mammograms, or their screening colonoscopies and you will be the Golden Child, the Wunderkind who will bring unity to the primary care force.  Trust me.  You will finally get an interesting patient who looks like undiagnosed lupus and you will be on fire presenting this amazing discovery when your attending will interrupt to ask when she had her last pap smear.  Routine health maintenance is just one of those important defining features of Family Medicine.  It’s their niche and they live for that sort of thing, taking the same satisfaction in getting their patient’s medical house in order as I get in discharging a drug seeker without the narcotics he was looking for.

There are also a few common conditions that will account for almost all of what you see.  A medical student, for example, who understands diabetes, how to manage insulin regimens, and what oral hypoglycemics to prescribe (and why) will double-secret pinky honor the rotation.  If he understood Asthma, Hypertension, and COPD he will walk on water.  If he believes in Fibromyalgia they will proclaim him Family Medicine Material and the full court press will be on to keep the other, more lucrative specialties from seducing him with their promises of interesting work and high salaries.

Things that Will Suck:

The complaining.  Family medicine is a specialty in the midst of an identity crisis and the angst of being the lowest-paid and least respected specialty is going to come through, loud and clear.  Somewhere, the specialty took a wrong turn and decided that social work and many other non-medical functions were part of it’s purvue which has only added to the confusion.

The key problem is that the “Family” is not an organ system which can be treated medically. Since we treat individual patients and not groups, to treat the family, Family Practice physician need to be internists, pediatricians, and OB-Gyns at different times during the day. Since there is no way to roll these three unique specialties into a three year residency, many Family Physicians feel as if they have become nothing but clearing houses for referrals to specialists which can be demoralizing and explains the quest for job justification.

But other than that philosophical crap which you may or may not care about as you hope to become an ophthalmologist and be above those kinds of concerns, if you don’t like routine medical conditions and predictability you will intensely dislike your family medicine rotation.  It’s as simple as that.

Oh, and the grading for the rotation, if you worry about this kind of thing, is more subjective than usual.  The best student in your group will barely pass if he can’t conceal his distaste for the pace and concerns of the specialty.

Cool Things About the Rotation:

I think everybody likes to play doctor which is pretty much what you will do on the rotation.  Family Medicine is what most of you imagined medicine to be like, at least those of you who have not been anal compulsively pursuing a plastic surgery fellowship since the eighth grade, and the immediate risk to the patients is so low that you have the time (as a medical student, that is) to really get to know your patients.

Call:

Bogus, as usual, but since you will only do call if your hospital has an inpatient Family Medicine service, you might slide out of it.  Since the census is small and you are unlikely to be attending medical school where the Family Medicine residency program is unopposed, your duties on call will probably be light and the admissions will be infrequent and fairly straight-forward.  Many Family Medicine services, for example, do not admit and follow critical care patients.

You will certainly not take home call like the Family Practice residents who, in addition to their regular duties, have a panel of pregnant patients threatening to pop at any time.  The logistics of this would just be too complicated.

Slacking Potential:

Terrible.  Clinic goes all day and you will have to be there.  And it can be a slacker’s nightmare as you may have to shadow an attending leaving you with no opportunities for hiding and sliding.  Still, if it’s a clinic rotation it will be a nine-to-five sort of thing so I wouldn’t worry about it too much.

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 7

Ask Dr. Bear

(Just some recent questions that showed up in the mail bag.-PB)

What Exactly is Wrong With “Patient Care?” You use the phrase like it were some kind of swear word but isn’t this our purpose as residents?

Of course it is. But “Patient care” is one of those nebulous phrases which encompasses so much in it’s definition that it can mean many different things to different people. In fact, your views on patient care will be radically different depending on how much of it you do and your actual level of responsibility for patients. To the adminstrators of your hospital, patient care means shoving a warm physician body, any body, into a slot in the schedule. If this means that a resident will cross-cover a couple of hundred patients about whom he actually knows nothing then that’s acceptable because the slot is filled.

Many residents, consequently, soon get the idea that residency training has something of a cattle-drive quality to it as our job, especially on call, seems to involve nothing more than wrangling large herds of patients in and out of the hospital. So while Patient Care is the ideal and calls to mind noble images of the selfless physician tending to the afflicted, a lot of it looks and feels more like patient processing. It has to be done of course, but it’s hard to get weepy and emotional about it.

As I have mentioned before, “Patient Care” is also used as a blunt weapon to beat down any reasonable debate on hours and pay. By default, apparently, every single patient in the world would be our responsibility if the hospital could only figure out a way to keep us funtioning without sleep. From this point of view, limiting residents work hours can only be construed as a crime against humanity and for a resident to suggest that he might like to get some rest can only be viewed as rank egotism.

Oh how the hospitals must have cried righteous tears when the current 80-hour rule was implemented.

Besides Patient Care, one of your other responsibilities as a resident is to learn. Unfortunately, the current system of residency training, which would collapse if the hospital was not allowed to over-work and deprive you of sleep, is not really an ideal educational environment. This is obvious to anybody who has ever tried to crack the books when they are post-call.

What, exactly, is wrong with the current system of residency training and how would things work in the Pandaverse?

The current system of residency training was devised over a hundred years ago and has not been substantially modified since then. It evolved from a more informal system of medical training which was almost a master-apprentice relationship. In fact, until the turn of the century, medicine itself was a fairly informal enterprise with very little standardization of training. Times have changed.

My biggest criticism of residency training is that it was devised for a more lesiurely era when the pace of hospitals was a good deal slower than it is today. As I have mentioned before, there were fewer interventions, far fewer medications, and much less to be done for most patients except to observe and hope that the limited supportive care available at the time would give the patient a chance to heal. One of my attendings, for example, related to me that when he was a young resident at our hospital, there were exactly three ventilators in the entire city. One of the jobs of the medical students was to “bag” the patients until one of the ventilators could be secured, often for hours at a time.

Today, the same hospital has close to eighty fully staffed Intensive Care Beds. And they are all occupied, usually by the kind of patient who could not have existed even fifty years ago when people routinely died of things we can treat today and could never have survived to become the kind of multiply co-morbid train wrecks which are now routine. Not to mention the hundreds of regular beds that are full of people who would have been considered insanely complicated patients by our collegues from the 1950s.

This is a good thing for the most part. It is true that we tend to get a little crazy with end-of-life care, often spending hundreds of thousands of dollars to preserve the anatomical functioning of people who maybe should be allowed to die peacefully, but I’m glad that I may have the chance some day to live beyond something that would have killed me if I had been born in the nineteenth century. The result of this is, however, that the hospital has been transformed from a sleepy hotel for the sick and a minor part of the urban landscape into a bustling hive of activity, almost a small city in its own right, and often the biggest employer and largest source of economic activity for many municipalities.

And there is money to be made. Lots of it. Hospitals are money-making enterprises in a way that would have been inconcievable even sixty years ago when medical care was cheap as it didn’t require much in the way of technology or support. The amount of money flowing through hospitals is staggering and represents a substantial percentage of the Gross Domestic Product. This is not necessarily a bad thing. In fact, the economic incentive is a powerful motivator for technologies that improve the standard of living.

But it is money and it is too much to expect a bureaucrat to worship both God and Mamon. Residents, the only employees who can work almost unlimited hours without extra compensation, are an economic boon to the hospital which can only maintain a staggering volume of patients because the majority of its physicians are working for incredibly low and fixed wages. Hell, Residents cost the hospital exactly nothing as the federal government pays them an average of $110,000 per year per resident, roughly twice the cost of their pay and benefits. Hiring an extra phlebotomist is a difficult decision for a hospital and requires budgeting meetings, reams of decision support, and bureaucratic hand-wringing at the highest levels. Covering the wards at night, on the other hand, is an easy decision.

“Make the residents do it. Fuck ‘em. It ain’t costing us a dime. We own those suckers and have their gonads firmly grasped.”

Imagine the heartache that would ensue if your hospital had to hire a hopsitalist to do your job.

The net result of all of these factors? Residents have been transformed from low-payed but not particularly busy apprentices working in a system set up primarily for education to low-payed and incredibly busy employees whose primary job is moving the meat and for whom education is secondary and often incidental.

The solution? For the hospital to admit that residents are employees and treat residency training how we do it in Emergency Medicine, that is, a shift system with a dedicated didactic block once a week. maybe residents need to work more than 40 hours a week but even 80 is ridiculous as it necessitates bi-weekly periods of sleep deprivation and profound fatigue that makes education almost impossible.

B-b-but Panda, you can’t possibly train a doctor without working him 80 or more hours a week as a resident. Are you saying that we need to extend residency training?

No. Residency training is hugely and completely inefficient with large blocks of your time frittered away by bureaucratic exercises that contribute nothing to Patient Care. There is, however, no incentive to change a thing in the current system. You aren’t costing your hospital a thing, remember, and even if you were laying in an ICU bed in a profound vegetative state, the hospital would still make $50,000 or so per year on your tube-fed, inert body. The ironic thing is that, with typical bureaucratic short-sidedness, the hospital could extract even more money-making (or money saving) work out of you if they streamlined things a bit.

Hey Panda, I want to do Emergency Medicine but if I can’t match into it, can’t I just match into Family Medicine and then work in Emergency Departments? It’s all just primary care, right?

Like most things, it’s all about money. As you know, Family Practice is probably the lowest payed medical specialty which also partially explains its unpopularity. Emergency Medicine pays, all other things being equal, almost twice as much as Family Practice. In the days before Emergency Medicine became a formal specialty, emergency care was rudimentary and Emergency Rooms were staffed by a motley collection of physicians of varying skill levels, some who liked working in the field and some who really couldn’t do anything else.

As the field of Emergency Medicine has evolved, however, the practice opportunities for non-board certified physicans are shrinking. Emergency Medicine has exploded in popularity (for various reasons which we will discuss in later articles) and securing a residency position leading to board certification has become increasingly difficult leading to an entry barrier to the field which many consider to be unfair.

The key question is whether you believe that Emergency Medicine is a legitimate specialty with its own unique body of knowledge that is not commonly practiced by other specialties. If it is, and I believe it is, then unless you have been working at it for many. many years before there was a specialty, you are out of luck and if you want to be an Emergency Physician, you need to get the appropriate training.

Family medicine concentrates on the diagnosis, treatment, and long-term management of common and non-life threatening conditions. Emergency Medicine deals with the diagnosis, treatment, stabilization, and short-term management of shit that can kill you sooner rather than later. Is there overlap? Sure there is. But there is overlap in every medical specialty. I do a lot of pelvic exams and know how to deliver a baby but I would never bill myself as an OB/Gyn. Where the family practioner sees the forty-year-old otherwise healthy man whose blood pressure has been creeping up and after a paternalistic discussion, prescribes him a regimine of inexpensive anti-hypertensives, the Emergency Physician sees the forty-year old alcoholic with a headache, visual changes, and a blood pressure of 240/130. The first guy can wait a few days to fill his prescription. The second guy is going to start squriting blood out of his ears shortly if nothing is done.

Now, it is true that the conventional wisdom is that Emergency Medicine is just primary care for the uninsured but this is more because the conventionally wise don’t understand what primary care is. We do see a lot of relatively minor things in the Emergency Department but these are fillers and something we do to keep busy in between the real emergencies. I did a year of family medicine. The patients I see in a normal shift in the Emergency Department, those who don’t even raise an eyebrow, are much, much sicker than anything I saw in my 48 Family medicine clinic days. We admit close to 20 percent of out patients. And a good percentage of those go to the ICU.

Can I be any less wishy-washy on the subject than that?

Ask Dr. Bear

Obels for Charon

Futility

On the last day of her life, your mother went on a spending spree. I intubated her at around 9AM and for the rest of the day we threw money at her, successfully keeping her alive until about dinner-time when her liver cancer finally had enough, gave us the finger, and showed us who was really in charge. It was not a pretty death, but then I knew it wasn’t going to be when I only just managed to jam the breathing tube through her vocal chords before they were obscured by blood and other unwholesome-looking fluids. Still, over the course of a very interesting day she got an expensive bronchoscopy , five or six lab draws, a central line, an arterial line, three units of blood, a chest x-ray, continuous nursing, pumps, fluids, two consults, monitors, blinking lights, and the usual buzzes and beeps.

We did everything but put a coin under her tongue for the Ferryman which, considering the outcome, would have been just as cost-effective.

The next time, please pay attention to what we have to say when we have “The Talk” like we did two weeks ago to tell you that your mother had passed beyond the limits of our abilities and all we could really hope to do was to ease her suffering as she died. Unfortunately, as we live in an egalitarian age which worships your autonomy, when you seemingly ignored our advice and said, “Do whatever it takes,” our hands were tied and we committed ourselves to two weeks of slowly torturing a dying woman. I understand how you feel about your mother. I have a mother too but you can’t have really wanted this. We coded and shocked her, what? three times in the last eight hours? It had to have hurt her the first time when there was actually something of your mother to bring back. After that, well, I just don’t know.

Not all life is priceless. Not even your mothers. When you said, “Do whatever it takes,” what you really meant was, “Do whatever it takes as long as I’m not paying for it.” But there are very real costs associated with medical care and somebody is paying them. I don’t mean to lay this burden on you but since you want the autonomy to make medical decisions, you need to have all of the facts. Would you have ignored our advice if you had to mortgage your house to pay for your mother’s last two weeks of futile care?

Medical care, like most resources, is scarce and there’s never going to be enough to go around. Somebody has to decide how it’s going to be allocated and for better of worse we seem to have elected you even though you seemingly have no interest or incentive in the matter.

I don’t think you made a good choice here. That’s all. Medical care is for the living. Your mother needed hospice and maybe to die at home peacefully.

This doesn’t mean I don’t think we should spend money on the critically ill. I don’t know how much a year or two of life is worth and we certainly get sick but otherwise highly functional patients who we can return to a happy and meaningful life. I’d hate to make that kind of decision based on simple economics, assessing the value of a year with actuarial exactitude and making decisions accordingly. On the other hand there is a difference between critical care and futile care. Maybe I can’t define the exact line separating the two but I know the difference when I see it. Perhaps you were too emotionally involved to make the distinction and it was unfair to leave it up to you. It’s hard to let go, especially as the popular culture has conditioned us to expect medical miracles although I don’t know what you were expecting with your mother. The eventual outcome had never really been in doubt and you knew perfectly well that you mother was not going to be leaving the hospital this time.

When I pronounced you mother and closed her eyes for the last time, the ancient stillness of the tomb was deafening.

Obels for Charon

Plantation Tales

Swing Low, Sweet Chariot

Old Toby wiped the sweat from his eyes, looked into the fluorescent lights, wiped his eyes again, and turned back to his work. At his side his fellow Resident Duke hummed a quiet spiritual in time to the rhythm of his pen.

“Sho’ is warm in dis’ heah ward, ain’t it Duke? I declare it done be warmer every day.”

Hush yo’ mouth,” said Duke looking around fearfully, “Dat uppity ‘breed oberseeyar done got his eye on me. Oh lawd, I be afeerd sumptin’ awful o’ dat man.”

They both stooped to their work and said nothing for the next few minutes except brief instructions on positioning the ultrasound probe. Old Toby cannulated the internal jugular vein, threaded the guide wire, and let out a long, slow whistle.

“Dat’s as fine as silk and as smooth as buttered cornbread,” he said admiring his handiwork, “Dah Massah gwine to be mighty pleased, mighty pleased to see such a sight.”

Both residents shouldered their stethoscopes and after ordering a stat chest xray (“To see if’n the the cath’ter had done gone down far nuf”) shuffled slowly down the hall to the next patient. Around them, other residents toiled in silence, occasionally shooting fearful glances at Big Tom, Dr. Calhoun’s half breed overseer.

Big Tom slapped his reflex hammer against his scrubs and watched in satisfaction as every resident in earshot jumped. He was a resident himself but rumor had it he was the product of a tryst between Dr. Calhoun, the attending, and Big Tom’s mother.

“Toby,” he yelled, “Quit yo’ dang blamed lollygagin’ and git’ ober’ to da Widow Franklin’s. She be in needs of dat manual disimpaction and it ain’t gittin’ done no how if you be skylarkin’ wit Duke. Git, y’heah?”

“Yassah, Boss,” exclaimed Old Toby as he and Duke broke into a run. Once out of sight of Big Tom, both residents slowed to an easy walk.

“Ah caint hep’ it, Toby, dat Big Tom jes’ askyers me an ah caint take it no mo,” said Duke looking around fearfully. “Ahs been talking to the NRMP and ahs fixin’ to run away.”

“Dang blast it, Duke,” said Old Toby, his eyes wide with fright, “Why you be doin’ a dang fool thing like dat?”

“Coz I be done wore out wid’ da work. When I gets up in da moanin’ I gets me to work straight away an my heart mos’ broke thinking o’ all da work I gots coming. I’s not gittin’ no sleep no how ‘cept fo’ a wink heah and a wink theah. An’t baint near ’nuff fo’ me to live. I be tired all of da time, Toby, tired so’s ah caint think straight an it plumb done wore me out what wid’ the scribbling o’ notes n’ da admitting o’ patients. I axe you, Toby, if it ain’t proper that a resident get him sum sleep an some time t’ sop his biskits n’ gravy?”

“Oh Lawdy! Say you ain’t a gonna do it,” moaned Old Toby, “Ah spec it gwyne to be a pack o’ trouble iffen you do. Remember Mars’ Johnson’s Resident Rex?”

“He done got clean away. I heerd say he lit out mighy quick fo’ a PM&R residency an’ he’s eatin’ high offn’ the hog, dressin’ in his finery and struttin’ around his hospital.”

“Why, if you bain’t nuttin’ but a chuckle-head resident,” said Old Toby, “Laws, he got away fo’ sho’ but da Mars Calhoun made the rest of us hoe his tabacky n’ take his call. Say you baint gwyne t’ run, Duke. The massah gwyne to be mighty perplexed.”

“Dang blame da massah,” said duke in a low voice, “Ahs gwyne t’be a free resident.”

Plantation Tales

A Patient’s Guide to the Hospital: Part 1

(The first in a series of public service articles for our many non-medical readers.-PB)

In the Emergency Department Waiting Room

Welcome to our Emergency Department. I hope we can take care of your problem. The fact that you are here at 3AM predisposes us to take you seriously. Nobody who wasn’t really sick would drag themselves out of their comfortable bed to sit on ersatz ergonomic plastic chairs reading six-year-old Newsweek Magazines rubbing elbows with the kind of people who have nothing better to do at 3AM.

That just wouldn’t make sense.

While waiting, keep in mind that unlike other customer-service enterprises, the Emergency Department is not first come, first served. We have a system to rank the severity of your complaint which we call “triage,” a French word meaning, “You ain’t really that sick, Maurice.”

The nurse will take you vitals, listen to your story, and if it sounds serious you will go to the head of the line. If your story is not that compelling, well, you may get bumped down a little. So don’t storm the counter demanding to know why the guy vomiting blood went right in while you’ve been waiting for two hours nursing a wicked post-nasal drip.

With this in mind, we come to our first important concept: If you’re not sick, don’t come. Despite the truly astounding medical advances of the last fifty years, we can’t do much for a cold, a mild case of diarrhea, gas, and any number of annoying but non-serious medical conditions. Over-the-counter remedies for symptomatic relief will work just fine, are available 24-hours a day in most cities, and you can be in and out of Wal Mart in ten minutes. That and some of your grandma’s common sense are all you really need and all we’re going to give you ourselves. Why spend eight hours waiting to be told this when you could be no better or worse in your own bed or on your own couch watching something other than the Fresh Prince of Bel-Air?

So stay home. I know you may not have health insurance but in this case it doesn’t matter. The common cold is the great equalizer afflicting king and peasant alike.

But let’s assume you’re sick. The second important concept is that you did not arrive by ambulance. This means that you may have had time to think about coming in. Did you bring a list of your medications? I most certainly do not expect you to remember them all but we need a little more guidance than, “I take three little white ones in the morning.” Think about either making a list or at least bringing your pill bottles. Most pharmacies will even print you a list and if you get everything filled at one place this is perfect.

It was a good thought bringing your pill organizer and I guess we can always painstakingly match each pill by shape, color, and marking in the PDR. But this takes time, a whole lot of time. We do have other patients and we are not just sitting back there drinking coffee talking to our stock brokers.

No we don’t have your medications on our computers. Amazingly enough, we probably do not have access to your medical records in our Emergency Department. There may come a time when everything is on a universal database but for the time being, at 3AM your regular doctor in Muncie, Indiana might as well be on Neptune for all the contact we can make. With this in mind, maybe a list of your medical conditions would be helpful. (I see that by-pass scar so I’m not buying that you have no heart problems.) Pretend that you want to get the best and most efficient treatment from a doctor who has never met you, knows absolutely nothing about you, and will never see you again.

In other words, make our job easy. I once had a lovely 94-year-old lady as a patient who had a binder with her medication list, a list of her allergies, her living will, and copies of her last four or five discharge summaries. That lady instantly got eight points on the ten-point scale. (Most of you start at a four or five) and more importantly, she got the best care possible because there was no guesswork involved. Hell, she even had the names and phone numbers of all of her doctors.

On the subject of being a walk-in, we make great allowances in our patients. Hell, if you’re sick, you’re sick and maybe you were too embarrassed to call the ambulance even if you should have. It is true that some people will dial 911 for a paper cut and some will drive themselves who are later admitted to the ICU. But if you’re not that sick, would a little attention to personal hygiene set you back on your schedule all that much? You may sit around your house in your underwear eating pork rinds indifferent to the daily routine of showering, brushing, and wiping your ass but seriously, dude, a visit to the doctor, while not requiring your Sunday best, is a special occasion.

A word on Children.

You know, if you’re poor you can get them insured under Medicaid. Really. And you won’t pay a dime for doctor’s visits or prescription drugs. It might take some effort on your part to look in the phone book for the county Office of Social Services but once you get them signed up and find a pediatrician, you will never have to bring them in again.

Look, I know little Quintravion threw up twice this evening but look at him now. He’s asleep. Before that he was running around terrorizing the place. It’s true that our threshold of suspicion is low for children but that boy does not look sick. Maybe a little ginger ale is all he really needed.

If you have Medicaid, shame on you. Your kids need to be in bed, not running around here. Not being able to take time off during the day due to your job is a better excuse than not wanting to pay a buck-fifty for a bottle of Children’s Motrin. Come on. I’ll write you a prescription for it but anybody with a pack of cigarettes sticking out of their purse and a cell phone should be able to scrape together a couple of bucks. Hell, I’d pay ten time that just to not have to sit with sick people.

No, I will not write you a prescription for ginger ale.

Out of curiosity, how many people, exactly, do you know who are up at this hour? You’ve been talking on your cell-phone non-stop since you got here. Give it a rest. I’m a doctor, a pillar of the community, and I like to think I have a few friends but I haven’t spent ten minutes this month talking on my cell phone. Hell, I leave it in the car most days. I just don’t have anything in my life important enough to warrant carrying it around, I guess.

There is no such thing as a volume discount by the way, at least not for us. If your other children aren’t sick don’t say they are just to get them checked because since you’re here, you might as well. In case you didn’t know it, there is a large paperwork burden associated with every patient, even those who are not really sick. A one second lie on your part means fifteen minutes of paperwork for me. Have a heart, lady.

Next: Yes, You Can Have a Sammich’.

A Patient’s Guide to the Hospital: Part 1