Screw Cuba, How About Them Albanians? (And Other Musings)

One More Time…

Let me try to explain this again. American medical care is expensive for everyone because the costs are shifted from one set of consumers to another. Most of us are not sick and except for the odd hospitalization for something unexpected don’t really require that much doctoring. There is, however, a small but significant subset of the population who use a terrifically disproportionate amount of health care. I write about this group extensively on my blog and they include the living dead vegetating in pre-death staging areas nursing homes, the multiply comorbid, and people who make bad lifestyle choices resulting in a state of perpetual symbiosis with the local hospital. Upon this group of people is brought to bear the full might of our technologically sophisticated but extremely expensive medical arsenal.

I treated a 79-year-old man the other day who has, I kid you not, eight stents in his coronary arteries, a history of three pulmonary emoblisms (emboli?), a greenfield fiter in his unamputated leg, diabetes, peripheral vascular disease, renal failure, a colostomy, a PEG tube, senile dementia, emphysema, and a string of minor strokes before the Big One that knocked out what looked like the entire left hemisphere of his brain. I have no doubt that the cost of his health care just in the last few years would be enough to pay for the health insurance of an entire Cuban province and probably runs into the millions of dollars, not one cent of which he or his family have paid or even expect to pay because you are picking up the tab with your outrageous health insurance premiums and twenty-dollar aspirins. Maintaining an ICU bed, for example, costs a typical hospital several thousand dollars a day and this gentlemen has spent months in the ICU while his family urges us to keep his heart beating regardless of the cost.
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In Europe, this patient would have died fifteen years ago, probably after his first heart attack. Maybe he would have gotten the first heart catheterization, maybe he wouldn’t, but as his comorbidities snowballed the Freeloader Kingdoms would have cut their losses and, while advanced treatments are theoretically available, the reality of rationed care would have finished him off. A Greek doctor of my acquaintance related to me that even what we consider routine critical care would be considered extremely heroic and almost unheard of over there.
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The argument goes that if this poor son of a bitch only had access to good primary care he wouldn’t have found himself in these dire straits requiring this level of care. Putting aside the obvious fact that many such patients in the United States have had excellent access to primary care (many of my ICU patients are retired from GM), and the dubious belief that primary care will keep people from cramming the metaphorical pie into their notional gob-holes, let’s asume that cheap primary care would have made this guy well and allowed him to live comfortably and productively into his golden years requiring nothing but a couple of inexpensive pills and a few doctor’s visits to manage relatively benign complications of his well-controlled medical problems. If this is the case and if all that is required to make the United States a Cuban-style health care paradise is cheap primary care, why should the government have to pay for it at all? In other words, if it’s cheap, why can’t people buy it themselves? A doctor’s visit here or there and a few pills probably costs less than most people spend on cable television. I know for a fact that one of my frequent patients can afford a thirty dollar a day marijuana habit (but won’t scrape together a couple of bucks for antibiotics at the local Wal Mart which practically gives away a long list of generic drugs) so a couple hundred a year for his doctor visits is a trivial amount.

Primary care is cheap. It’s so cheap that it makes no sense giving it away for free, particularly when to give it away is going to require the massive bureacracy typical of all government solutions, a bureacracy that will inevitably stifle everything that is good about American medicine and turn us into just another society with excellent access to health care unless you really get sick at which point it is hasta la vista, baby. For the sake of your fear of cutting into your blunt money, you are willing to turn over close to twenty percent of the economy to people whose only talent is that they have no talent for anything but government.
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Still, nothing is really going to change. All we’ll be doing is throwing bad money before good because while a small percentage of patients who are destined for the comorbidity jackpot may have a come to Jesus moment where they decide to modify their behavior, most will continue as if nothing happened and arrive on schedule, after hitting all the expensive milestones, to thier fabulous yet terminal month in the ICU.

It’s not as if the public will actually accept rationing of care for their demented granny. Any politician who suggests that to control costs we need to put her down like a dog (so to speak) is destined to go down in flames. What is will happen is that we will continue to spend fantastic amounts of money on health care and when the numbers get too alarming, measures will be taken to control costs that, by removing the incentive for productivity, will make the problem worse.

Or Look At it Like This…

Consider the American military in comparison to the typical European military. The American military is an expensive, technologically sophisticated organization that is twenty or thirty years ahead of anything the Europeans can field. We almost can’t share the same battlefield because of the speed and sophistication of American weapons, command and control, intelligence, and logistics. The American military can do things and go places. The Europeans have difficulty doing anything including finding reasons to maintain the militaries that they have.

But the Europeans do spend less and they do get whatever it is they want from their armed forces. And yet the capability to transport a couple of Marine Regimental Combat Teams or an Army Armored Brigade anywhere in the world on short notice doesn’t come cheap, nor are carrier battle groups operated on a shoestring. You get what you pay for. A primary care military with conscripted soldiers who don’t expect to do much is fairly inexpensive and looks pretty good until you have to make it do something. A working war machine isn’t pretty and to make it do something requires the dedication of motivated troops and frightening amounts of money.

Life Expectency

With the exception of Japan, the average life expectency of every country in the developed world hovers around 80 years. The average life expectency in the United States is 78 years. In the European Union it is about 79 years. The difference is nothing to get excited about and seems to be unrelated to per capita expenditure on health care. Those cheese eating surrender monkeys (the French I mean) may be healthier than Americans but they only live, on average, a couple of years longer than we do. It may be true that they only spend half on a per capita basis what we spend on health care but perhaps past a certain point there is no relationship between life expectancy and health care expeditures. Sure, you’re screwed if you’re from Namibia (average life expectancy of 40 years) but you’d be hard pressed to make the case that we get all all that much of a bang for our bucks or that European health care is better based on a a few months difference in life expectency.
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I mean, the Albanians spend next to nothing on health care (36 bucks per head per year) and they still live almost as long as the typical citizen of the European Union. How on Earth is this possible? Albania is a shit hole. The only Third World country in Europe. Do French politicians propose that the EU go to the Albanian system to save money?

Perhaps because life expectency in part depends on cultural factors which have nothing to do with the medical care, it is a poor indicator for its quality. I have travelled extensively in Europe and I have never seen anything remotely close to the five and six hundred pound behemoths that hardly raise an eyebrow in our hospital. But this is more a result of the thirty buffet-style restaurants within two miles of the place than some hard-to-define shortcoming of our health care system. I know for a fact that many of these monsters will enjoy terrific access to health care untill the day their bad heath finally catches up to them and they become a statistic dragging down our average life expectency. If you look at it this way, and factor in things like gang violence which decreases the life expectency of black men to 67 years, the premature babies who we try to save at gestational ages which would make the Europeans laugh contemptuously, and half a dozen other cultural factors which have nothing to do with health insurance it is a wonder that we live, on average, as long as we do. Apparently, for every Tupac harvested early to the Lord we have a ninety-year-old vegetable sucking life through plastic tubes bringing up our average.

Addendum: I propose the following thought experiment. I live in an average Midwest city with a population of around 200,000. Let us charter a bunch of airplanes and exchange the non-medical population of the city with the population of a similar-sized French city, say Toulon. Let us then follow the two cities for the next couple of years and see how they fare in regard to health care costs. I predict the following: We will get a much deserved vacation, working at our hospital will be a cake walk, and those poor French bastards will reap the adipose whirlwind as their health care costs skyrocket and they feverishly brush up on their atrophied critical care skills. Either that or when we switch back we are going to be minus a lot of our citizens.
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Next: The annual “Welcome to Intern Year” article. I promise.

Screw Cuba, How About Them Albanians? (And Other Musings)

Kabuki Medicine and other Wonderful Tales

Kabuki Medicine

In one month I have had Mary as a patient four times. I have also noticed her roaming restlessly through the department on days when some other resident had the bad luck to pick up her chart. I would not be exaggerating if I said that she has been a patient in our department thirty times this year and the Lord only knows how many times at other Emergency rooms in the area. She is a huge consumer of emergency services and no one dares tell her to pound sand when she presents with one bogus complaint or another because one day, after crying wolf for her whole life, she is really going to be sick and if she dies the usual compassion fascists will descend on us like self-righteous harpies.

Thus do we regularly ignore common sense and, putting on our best kabuki faces, take every episode of chest pain, abdominal pain, shortness of breath, and near-syncope completely seriously pretending that we have not spent hundreds of thousands of the taxpayer’s dollars ruling out everything except drug addiction. It would be more cost effective if we just gave her perscriptions for all the oxycontin she wanted provided she limited her visits to once a month. Instead we enact the the traditional Kabuki drama where she assumes the role of a patient and we pretend to be her doctors. We stamp and posture, reciting our ritualistic lines while she demurely assumes the character of someone we actually can treat. Five acts later we discharge her, plus or minus a six-pack of vicodin, depending on how badly we want to get her out of the department.
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File this under getting what you pay for. Putting asided the usual policy wonkery, the real problem of American medical care is the complete absence of common sense. Mary is not unique. She is just a very visible symbol of a society that is ridiculously risk averse and consequently ridiculoulsy over-doctored. In a perfect world, someone would meet her at the door and say, “No. You are not getting drugs here.” If she departed chastened from our door and died…oh, let’s just say from a perforated bowel… a reasonable jury, assuming the case ever went to trial, would decide that it was a darn shame but understandable given her pattern of abusing emergency services.

Of course this would never happen. In the real world we are cautious to the point of foolishness, at least if we equate foolishness with a cavalier disregard for money.
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Consider, as one example, the typical cardiac work-up and the vast sums of money wasted every year on diagnostic testing and empiric treatment of patients with ridiculously low pre-test probabilities of being sick. (In other words, they are not sick.) A young male with no risk factors for heart disease should not need a complete cardiac work-up when he presents with chest discomfort as it is almost certainly going to end up being musculoskeletal pain, reflux, or anxiety. And yet the patient inevitably gets the whole enchilada including an expensive stress test and occasionally an admission if he is deemed to be unrealiable for follow up (because if he is told to return in the morning for his stress test, forgets, and dies three years later it is our fault). Now, it may come to pass that one day, out of ten thousand thirty-year-old otherwise healthy men you will isolate the one who does, in fact, have early coronary artery disease…but then you probably would have picked him out just from the history and review of systems. I don’t deny that if I were that one guy I’d be pretty happy that our system is structured to spend billions protecting against lightning strikes but the fact remains that we are spending billions with a very little to show for it in actual treatment or prevention of morbidity.

My point? I am getting tired of saying it and I will soon stop. Because of the highly litigious nature of American society, there is no incentive to exercise common sense. In fact, there is a perverse incentive to spend money like drunken Marines in a brothel because there is no allowance in American medicine for mistakes. The standard of care has become absolute zero-defect which costs money…but the key is that our system is so adept at shifting costs that it always appears to be somebody else’s money.

Potemkin Medical Care
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Cuban health care is so good that thousands of Americans risk their lives every year on flimsy boats and makeshift rafts in a desperate attempt to make it across the shark-infested waters of the Straits of Florida. Many perish in the endeavor and the 90-mile strait is littered with the floating corpses of uninsured Americans, many still attached to their now empty home oxygen cyliinders.

Ha ha. No, not really. Still, as the idee fixe of the pseudo-intelligentsia is the efficiency and general superiority of Cuban health care it is only a matter of time. We’ve all heard the mantra. The Cubans, it seems, spend a twentieth per capita of what we spend on health care but, mirabile dictu, have better outcomes and better access to medical care. Michael Moore, a man who knows as much about medicine as I know about making documentary films (i.e. nothing), has even made a movie based on this premise.
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Leaving aside the fact that Cuba is a Soviet-style dictatorship where the official statistics are manipulated to show the Dear Leader in the best possible light, ignoring for the moment that Cuba has the usual three-tier medical system of every worker’s paradise (one for the apparatchicks, one for the proles, and a Potemkin hospital or two for the tourists), and even forgetting the inexplicable love of the American left for a dictator and a society from which people are willing to risk death fleeing…leaving aside all of this I just want to know why, in a society with a per capita income of just 300 dollars per year they manage to spend so much money with so little to show for it.

The per capita income in the United States is about $40,000 per year or about 130 times that of a typical Cuban. Cuban doctors make about three hundred dollars per year or about half of what the typical American family, even those in the dependocracy, spend for cable television. Cuban nurses probably make what my young children get as an allowance. Since labor costs are the biggest expense in health care both here and in Cuba, I just want to know why the Cubans are spending so much money on health care and still have a life expectancy less than the United States. Something doesn’t add up. Cuba is 130 times poorer than the United States and yet, in relative terms spends five times as much on health care.

Oh my long-suffering readers, do not yearn for Cuban-style medical care in the hopes that it will be cheap. It’s cheap for Cubans because Cuba is a third world country where everyone is poor. In Cuba a doctor might be willing to work for fifty bucks a month but in the United States, any enterprising teenager can make 20 times that amount working as a taco jockey. In other words, unless you plan on making everyone poor, good luck getting people to work at the hospital wiping yer’ grannies ass or coming at night to admit a patient for the kind of wages it would require to Cubanize American medicine.

Kabuki Medicine and other Wonderful Tales

Panda-pouri

Free at Last, Free at Last

After six years of screwing around, I finally have a job. As many of you know I had to repeat my intern year because of a little something I like to call The Biggest Fucking Mistake of My Life. I won’t mention where I did my first intern year because its very name would serve as chum to attract the fearsome creatures guarding its reputation, not to mention awakening Those Who Guard The Sacred Flame of the specialty from whose clutches I barely escaped.
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So I’m done with off-service rotations and as of July first will be a fully functioning second year Emergency Medicine Resident (but a PGY-3, you understand). The best thing about this is that I will be working predictable shifts for the rest of my residency with no call and the ability to sleep every day. I actually finished my off-service rotations a few months ago and have been working in this manner ever since. It’s pretty cool but I want to caution those of you thinking of matching into Emergency Medicine because you don’t want to work hard to think again. While it may be true that at most programs you will get what seems to be a ridiculous amount of free time (we work 14 shifts per 28-day block), at the end of a stretch of four shifts you are going to be wiped out, in a good way mind you, but wiped out none-the-less.

The pace at a typical Emergency Department that can support a residency program is relentless. I don’t deny that other residents work hard. I’ve done enough off-service rotations to know that they do. On the other hand the long days of, say, an internal medicine resident are broken up a little with conferences, the occasional slow clinic day, and frequent lulls in the action where one may take a breather which is not the case in the Emergency Department.

In Emergency Medicine when we are at work we are working, usually flat out, for the whole shift. As most residency programs are in what amount to charity hospitals there is never a shortage of patients and they will keep coming and coming, at all hours, and for a terrific variety of chief complaints. If you are ready for this and don’t mind multi-tasking then you will enjoy it. If not, this is not the specialty for you.

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I Try to Be Empathetic But Come On Now….

I actually have a great deal of sympathy for addicts. It’s hard not to as they are some of the most miserable human beings you will ever meet. It can’t be much of a life bouncing around the various Emergency Departments in town looking for your next fix, getting more feral as the delay between presentation and your lucky strike, a new resident who has never seen you before, stretches to minutes and then hours.

Where addicts get the money for their habits in between emergency department visits is sometimes a question you do not want to ask. While it is true that some have money from disability and some have family or friends from whom they steal, many do unspeakable things for their drugs, things that would curdle your blood to think about.
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There are two distinct philosophies regarding drug seekers. One school of thought believes that it is easier to give them a little morphine or vicodin with the goal of getting them the hell out quickly before they become a space occupying lesion. The other school believes that giving narcotics to the addicted enables drug-seeking behavior and encourages the waste of resources, sometimes leading to delays in treatment for people who are really sick. I probably lean towards the former school of thought because my first instinct is to give everyone the benefit of the doubt. Laughable as it may seem, even drug seekers may occasionally have a real medical problem so I try to be open minded.

But for God’s sake, “Rectal Bleeding” is not the thing to fake if you want drugs. Not only does it involve a complicated and expensive workup but it is going to require me to stick my finger up your ass, not something I generally like doing. And when I get your stat hemoglobin and hematocrit and it is normal I am going to be both disappointed and angry. It’s not as if your stable vital signs and completely benign appearance didn’t tip me off at the beginning of our visit. Indeed, the fact that you couldn’t prounounce the name of the only pain medication to which you weren’t allergic, something starting with a “D,” made me a little suspicious. And then when I discovered that you had a complete workup for rectal bleeding three days before with no findings whatsoever it was disappointing…and embarrassing for me because I was really gung ho to save yer’ friggin’ life until I got the old chart.
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I also want to point out that if you are an addict and present with constipation after going on an oxycontin binge, reaching back and pulling feces out of your ass is not going to make me want to help you. You accused me of not caring but there is no way I am going to get close to you until you put your hand, the one covered in fresh manure with half-inch long nails under which is packed several year’s worth of other unspeakable things, down on the bed and stop trying to grab me. If you tried that on the “skreet” you’d get your ass kicked or arrested. Why is it all right in the Emergency Department? I understand that you’re jonesing but it is too much to expect of nurses and doctors to put up with this. If I made the rules I’d taser you and throw you back out on the street.
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Wille Sutton robbed banks because that’s where the money is so I guess it makes sense for you to come to the Emergency Department because that’s where the drugs are. But being your dealer is not really our job and athough this would shock you, neither is taking care of you in the hospital or solving your personal problems.
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And don’t kiss my ass either. I am not the best doctor in the world and your telling me I am just reminds me how crappy it is to be a resident at the bottom of a steep learning curve. Thanks for ripping that scab off and rubbing salt in the wound. If you just kept your mouth shut and complained of back pain like every other drug-seeker I would have probably given you something…except for that thing with your ass of course.

Silver Bullet

I am no luddite. While I am not on the cutting edge of technology I generally embrace it willingly when it is mature enough to simplify my work. Lately however I’ve had a change of heart about PDAs. Oh, I was enthralled four years ago when I was first introduced to them. Here at last, it seemed, was the one device that would put the bewildering immensity of medical knowledge at my fingertips and eliminate the need to carry the myriad pocket reference books that never really seemed to contain what I actually needed to know.

That’s all most us want. A simple reference book to carry around. A silver bullet, if you will, the one thing that will do the trick. The PDA is not it. Maybe it’s because the thing is so expensive. I already dropped one and fractured the screen. I got a new one from my program but it’s only a matter of time before it is damaged or stolen leaving me $300 in the hole if I want to replace it. Perhaps I have grown to dislike the complexity of the device, especially downloading software which never seems to work for me and my seven-year-old Toshiba laptop. It probably takes less authentication and verification to launch a nuclear missle then it does to download Epocrates. And the silly thing keeps begging me to update it, to synchronize it, and to hold its hand and comfort it.

Supposedly using the PDA to keep track of your patients is all the rage now but unless you are at a hospital that is totally committed to integrating medical records wirelessly and uses bullet-proof software, it is probably more trouble than it’s worth. An index card with the patient’s sticker at the top is actually a lot quicker, especially if you learn to only recored pertinent information. I also find that I can remember the important things about my patients and I don’t need to write much at all.
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So I have ditched the PDA and most of my pocket reference books. In their place I carry a Tarascon Pocket Pharmacopia for a drug reference and the most excellent Tarascon Adult Emergency Medicine Pocketbook. The Emergency Medicine Pocketbook in particular, while as compact as all of Tarascon’s Pocketbooks, is packed with nothing but useful information. It at least tells you how to start the workup for the great majority of presenting complaints. Anything else you probably have time to look up later.

Just something to think about, especially those of you starting intern year in a couple of weeks. The Internal Medicine/Critical Care pocket book is a pretty good reference for most of your rotations.

Panda-pouri

Kingdom Come

I could count the openings in the radiator grill of the truck that killed me and as I lost conciousness I noted with satisfaction that it was a good old-fashioned International Harvester of a kind that I had seen thousands of times but never from that close.

And then the cool darkness closed around me and I slept.

After what seemed like years I was awakened by a faint white light in the distance. I saw someone beckoning to me from the light which became brighter as it drew closer and I was afraid. Afraid to leave the comfortable darkness. Afraid of the long swim to the light which now burned with a cold incandescent fire.

“Come into the light,” said the voice and as I rose towards it I recognized the speaker.

“Uncle Jedidiah?” I said, “Is that you?”

“None other,” said the voice as he extended his hand to pull me firmly out of the darkness.

“I haven’t seen you in forty years,” I said in wonder, “Since you died, I mean. Aren’t you dead?.”

“Oh, I’m dead, as dead as a doornail. I’m sorry to be the one to break it to you but so are you.”

“I figured as much,” I said, “Where am I? Is this heaven?”

“Not quite,” Replied Uncle Jedidiah, “You’re in the Purgatory Room.”

“Purgatory Department!” corrected a winged creature carrying a flaming sword, “It’s a department, not a room.”

“Uh, right…anyway, you’re in the Purgatory Department waiting to be admitted to Heaven,” said Uncle jedidiah, “And I’m afraid it’s going to be a while.”

“You mean you’ve been waiting for forty years? What gives, Uncle? I remember you were a pretty good Catholic, went to mass every week, said your prayers. Even the priest thought you were a pretty righteous guy. If anybody could get to heaven quickly surely it would be you.”

“Oh, I did all right when I was alive,” said Uncle Jedidiah looking down modestly and pretending to examine his fingernails, “I ate a little meat on Friday and cursed a little. I wasn’t perfect you know.”

“Yeah, but surely a couple of Hail Marys and a few Our Fathers could have covered it,” I was incredulous, “Fifty years? Come on now. What chance do I have?”

“Well, it’s not exactly merit-based anymore now that they’ve gone to a Single Penance system so your chances are as good as anybody else’s.”

“Single Penance? What’s that?” I asked.

“It’s new. Instead of being responsible for your own sins, somebody repents for you so you don’t have to do it yourself. It’s supposed to ensure equal access to Heaven for the under-repentant,” Said Uncle Jedidiah.

“So that explains the wait.”

“At first it wasn’t too bad,” said Uncle Jedidiah leading me around a group of bikers eating vending machine locusts and honey, “They started with the Protestants which was all right, I guess. I mean I could see the rationale for that. But then they decided to start letting in the Hindus and the Moslems. I don’t have to tell you the penance problems that posed.”

Uncle Jedidiah motioned me to a place at the end of a line which stretched for miles.

“Pretty much anybody can get in now,” He continued,”You really have to have committed some kind of major crime against humanity not to…which explains why the Back Street Boys might not make it. But pretty much no matter what you do somebody else will do your penance. About the only people they don’t let in are the Methodists, for obvious reasons, but other than that it really makes no difference what you have done.”

“Can’t we just repent ourselves and eliminate the wait?” I asked taking a number from a brazen tripod which gleamed with a holy luster.

“Well, of course not,” said Uncle Jedidiah looking puzzled, “That wouldn’t be fair, now would it? That would give people who were responsible and self-disciplined an unfair advantage compared to, oh, let’s say pedophiles. Surely we can’t have that.”

“I don’t know Uncle, it sounds good but who’s doing all of the repenting if nobody is expected to do it for themselves?”

“Well, there’s the rub,” said Uncle Jedidiah ruefully,”There is apparently a distinct shortage of pentinents. At first they had the Archangels do it but there are only so many to go around. Then they started using Saints but even they have their limits and I know I don’t have to tell you how long it takes to make one. Eventually they started using mid-levels like Saint Assistants and Saint Practioners.”

“How’s that working?” I asked looking far into the distance at the line ahead of me which wound around pillars of clouds upon which, written in blazing letters of English and Spanish, were admonishments keep all manna in closed containers and to rate your sin on a ten-point scale.

“Here comes one now,” said Uncle Jedidiah, motioning to an officious looking fellow making his way towards us, “Ask him yourself.”

“Hi, I’m your pentinent-providor,” said the fellow, “I’m not actually a saint but I am just as well trained despite the fact that unlike saints who toil and suffer on earth for many years, often enduring martyrdom for their faith, I went to a rigourous two year program which cut out all of the useless stuff.”

A Seraphim, six-winged, rolled his many eyes and shook his head sadly as he flapped by.

My providor shot him a dirty look and just as he opened a book which looked suspiciously like a gold-plated DSM-IV, I felt a slight tingling in my chest like a distant electric shock. Then another which felt stronger. The Purgatory Department started to fade.

“Oh well,” said Uncle Jedidiah, “I guess i’ll be seeing you later. Just some advice. twenty years from now don’t ignore that rectal bleeding. I’m just saying…”

And then I gasped. The pain flooded over me and I was back.

Kingdom Come

Socialized Medicine: Survival of the Fittest (Addendum)

See, you folks don’t get it. If all you expect the government to provide is crappy and relatively inexpensive primary care and would be content to eschew the expensive, admittedly low-yield technological and labor intensive medical care that we currently waste on the elderly, the terminally ill, and those with extremely complicated health problems like they do in most of the Socialist Freeloader Kingdoms…if this is what you want then why do you need the government to provide medical care? After all, in the big scheme of things a visit to your family doctor two or three times a year is not going to bankrupt the large majority of Americans. Surely even most of my poor patients could but give up their cell phones and instantly have the wherewithal to afford to take their children to a pediatrician now and then.

It’s the ICU stays, the heart caths, the chemotherapy, and half a hundred other treatments and procedures not typically associated with primary care that suck up most of the money. If you eliminated most of these things, none of which are even remotely available to most of the people in an advanced but highly socialized country like Greece, we too might be able to brag about our low per capita spending on health care. As an additional benefit, after a brief period of turmoil in which the usual helpless and useless patients who consume the lion’s share of medical care dollars died out in a Darwinian mass extinction, we could at last get down to the serious business of making our statistics look good.
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The point is that what you want and expect from the government, the thing that sends you into fits of rapture as you justify the more advanced priorities of the Nanny-States-Across-the-Water which stress primary care and prevention over our highly advanced reactive medical care, is so ridiculously easy to provide for yourself that it would be criminally stupid to structure society to provide it as an entitlement if for no other reason than it would involve shoveling even more of the personal wealth of the productive sector into the voracious maw of government. Your money, money that is not just paper or electrons but a voucher for your hard work, will be frittered away in the usual bureaucratic orgy of waste and inefficiency and contribute nothing to the prosperity of the nation.

All for the sake of avoiding having to pay for a couple of lousy doctor visits.

Socialized Medicine: Survival of the Fittest (Addendum)

Socialized Medicine: Survival of the Fittest

(My mother, who is an avid reader of my blog, is a native of Greece and while a fierce partisan of that country is never-the-less perplexed at the love so many of my readers have for socialized medicine of the kind which is the rule of life over there. I offer this brief description of a typical socialized system in a modern European country.-PB)
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“Apoklistiki Nosocoma”

The hottest new career in Greece, a country with socialized health care and my family’s ancestral homeland, is the Apoklistiki Nosocoma, or “Private Nurse.” Because the public hospitals are so understaffed families routinely hire one of these trained nurse to watch over their relative while the low-paid government nurses do whatever it is they do for their small salary, a salary which is just enough to convince them to come to work but not enough to actually get them to do anything.

These private (or “elite” nurses) are brokered through the public hospitals in a tacit admission that the socialized system cannot provide decent medical care to the people.

But that’s how it is when nurses (or anybody else for that matter) are employees of the state and have jobs from which they can be dislodged only by the apocalypse or another Persian invasion. They will certainly not be fired for ignoring the patients. Not only is the pay low but, with the exception of a few zealots, there isn’t exactly a long line of Greeks waiting to work for those wages doing the kind of work that our well-compensated nurses do automatically. There are no incentives to work and no penalties for not working. The results are predictable. Not only are Greek public hospitals understaffed but the staff in ‘em are not exactly chugging away efficiently.

“Fakelaki”

Of course, if you want anything done in the Greek public medical system you can always pay extra for it with a well-placed bribe. Maybe a couple of hundred Euros in a fakelaki (envelope) to the general surgeon to put your father at the head of the line for a colectomy. Perhaps some well-placed Euros to the charge nurse to make sure she watches your sister. My mother, who lives in Greece, relates to me that this system of bribery is endemic and almost institutionalized. In a country where doctors who elect to work for the state barely make what a garbageman makes over here, not only are there shortages of trained doctors in the public system but they have very little incentive to make the system work and the fakelaki is necessary and expected.

In our country a homeless wino can be brought in for gastrointestinal bleeding and within 24 hours have everything including a sigmoid colectomy and a kitchen sink thrown at him while he is cared for no differently than the paying customers. No bribe is required and the concept of expecting one is unthinkable. In fact, our system, although expensive, provides such good care to everyone that the VIP and the wino are indistinguishable as patients.

In Greece on the other hand, enjoying as it does the bounty of socialized medicine, there is a three tiered system. In the first tier are the private hospitals which are the equal of anything we have in the United States. Unlike our hospitals however, they are in no way charity institutions and only cater to the wealthy. In the second tier is the public hospital system where those who can afford it bribe doctors and nurses and even hire maids to clean their relative’s otherwise filthy rooms. In the third and bottom tier are the poor who lay in cots in the hallways of the crowded public hospitals relying on their relatives for the basics of life and nursing care.
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No relatives, no care. Greek public hospitals provide only the rudiments of services to their patients. The condition of the food service in most of them, for example, would be a scandal in the United States. Patient are fed indifferently from rat and roach-infested kitchens and the concept of nutrition seems to be unknown. It would be a national embarrasment except, in typical European fashion, the Greeks take great pains to criticise the United States while their own post-operative patients slowly starve to death. An ironic state of affairs in an otherwise modern European country.
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Even getting admitted to the hospital is a difficult process requiring the ubiquitous fakelaki. We would find it hard to believe accustomed as we are to almost instantaneous access to the full panoply of medical resources but in Greece if you have a life-threatening condition, say colon cancer or PORT-score maximizing pneumonia, and you rely on the socialized system you are probably out of luck and could die before you are admitted. The waiting list for what we consider to be routine medical care is hopelessly long.

And things like hemodialysis or Critical Care? Not if you are elderly or poor. You are going to die, just like Darwin intended, because in Greece as in most socialized countries they do not keep the weak and the helpless alive when they become a burden to the state. That’s the secret of socialized medicine. It’s like Logan’s Run. When your life-clock runs out you are done. Finito. Buh-bye. So sorry. Appreciate the taxes and everything but now it’s time to pay the bazouki player.

What’s my point? Nothing really, except you get what you pay for. Providing the high level of medical care that is expected by the American public is not cheap. Attempts to nationalize, socialize, quasi-socialize, or we-swear-we’re-not-going-to-socialize will do nothing to lower costs unless medical care is strictly and severely rationed. Oh sure, you can get yer’ stinking ineffectual primary care provided by a poorly-trained Nurse Practitioner but when your heart starts to give out or you need a new knee, well, you will see the truth to the adage that free health care is great as long as you don’t need it.

Socialized Medicine: Survival of the Fittest

Ask Yer’ Uncle Panda….

Say Uncle Panda, I notice you haven’t written about chiropractors. What do you think about them and chiropractic in general?
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Chiropractors serve a useful role in society, particularly when it comes to taking some of the pressure off of used car salesmen who would otherwise have the market cornered on chicanery. Nobody likes to be the only crook in town you understand, and if chiropractors are good for the self-esteem of used car dealers I’m all for ‘em. Other than that there’s not much use for chiropractors except to keep second-rate strip malls in business as they make that long descent from shopping mecca to consignment stores and karate studios.

On one hand you have the straight chiropractors who preach a strange religion where manipulating the spine can take the place of vaccines and cure all manner of diseases from cancer to your Aunt Dottie’s lumbago. On the other are the so-called “reform” chiropractors who confine their practice to musckuloskeletal complaints. Six of one, a half dozen of the other. Despite the occasional studies showing that it has a slight advantage over placebos in the relief of chronic pain and other fuzzy symptoms, chiropractic is a lot of sound and fury signifying little or nothing. For the money people spend and the effort they put into it (chiropractic school is four years, after all) I guess I’d want a little more than a slight improvement over a placebo. Just for my self-respect, you understand.

The basis of chiropractic is the theory that misalligned vertebrate (called “subluxations”) are responsible for disease. The old school chiropractor will shoot a plain film of your spine and use this as a basis for manipulating it back into position despite the overwhelming evidence that not only do otherwise healthy people have asymptomatic misalignments in their spines but there is no way to change the alignment anyway short of orthopaedic surgery.

But do what you want. I don’t care.

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Hey Uncle Panda, I’m considering Emergency Medicine but I’m concerned that it’s just glorified primary care. What say you?

That’s ridiculous, at least from my perspective. As many of you know, I did a year of Family Practice and while I disliked it intensely, it at least gave me a taste of primary care. Emergency Medicine is nothing like primary care.

Here’s what I saw on a recent shift: Two acute MIs (one with significant ST elevations), one acute pancreatitis with nausea and projectile vomiting, a baby with meningitis and CSF that looked milky when I did the lumbar puncture, a motor vehicle accident with bilateral tibia fractures, a tylenol overdose, vaginal bleeding that turned out to be an incomplete abortion, a couple of strokes, a severe COPD exacerbation, a third nerve palsy (which I diagnosed without an MRI, thank you very much) and the usual minor stuff which, although minor, was still more “urgent” than the usual primary care fodder.

People go to their family doctor for diabetes management. They go to the Emergency Department for diabetic ketoacidosis or when their foot is rotting off as a consequence of distal peripheral neuropathy. That’s the difference. I think I see more truly sick patients in one week in the Emergency Department than I did in a year of clinic in family medicine where, on the rare occasion when somebody was really sick they got sent to the Emergency Department.
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Now, it’s true that a lot of our patients could be better served at an Urgent Care. On the other hand one of our biggest source of customers are the local Urgent Care clinics, many of which are staffed by midlevels who have the good sense to drop back and punt.

I think a lot of folks don’t really understand primary care which is the long-term management of chronic conditions and not something we do in the Emergency Department, even if we wanted to which we don’t. We refer to primary care almost as much as they refer to us.

The truth is that you get so used to really sick patients that it begins to seem like primary care.

I am not busting down on primary care and Family Practice in particular. Primary care is neither easy nor quick. That’s why residency-trained physicians need to do it. The reason mid-levels do it is because nobody else will and because, cobra-like, they have mesmerized the Family Practice physicians who are their natural prey into accepting them as equals.

How long does it take to write an article for your blog and where did you learn to write so well?

Some articles write themselves and some I have to sweat over for days. I do experience periodic writer’s block and can go a long time without a decent idea (like the past couple of weeks). I suppose I could always write about how much residency blows but I don’t want to be a one trick pony. Besides, that would be like playing a crowd for cheap laughs. It’s too easy.

I also write most of my articles late at night when I should be sleeping. I hope that you, oh my critics, appreciate this when I don’t provide footnotes and an exhaustive bibliography. I just don’t have time. And I blog for fun so while I feel a responsibility to my readers to provide interesting articles, I do have a real job and to be honest, I make more moonlighting for half an hour than I do from the advertisments on my blog for a month.

In other words, this blog is a labor of love and not a money-maker so sometimes responsibility trumps fun.

I am flattered that many of you think I am a good writer. Let’s just say I’m working on it. I have pretty good role models who include Herman Melville, Mark Twain, Anthony Burgess, George Orwell, Charles Dickens, and Joseph Conrad to name a few. People ask me what I think about the Da Vinci Code. I didn’t read it. I don’t read crap. Period. I used to, of course, but after I discovered Robert Graves I have never looked back.

Read the first page of “Bleak House” or “1984″ and compare it to the typical offering at Barnes and Noble and you will see what I mean. Most writing, like most popular culture, is excruciatingly bad. Almost painful to read. I’m probably not too much better but at least I can see where I need to go. One day I will have time to really write something meaningful but not right now.
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Paradoxically, the rest of my tastes are completely plebian.

Ask Yer’ Uncle Panda….

Curbing Health Care Spending, Belling the Cat, and Other Dangerous Activities

Where the Money Goes

American medical care is expensive and only getting more expensive. I blame the nurses. Think about it. Who is always at the hospital drawing their princely 25-to-40-dollar-an-hour salary? Who must provide continous coverage for the patients? Who are the most numerous employees of the hospital?

Nurses, that’s who.

Think about it. Doctors may make a lot of money but in most hospitals they are pretty thin on the ground. On the other hand you can’t swing a JCAHO-compliant dead cat without hitting four or five nurses. They’re everywhere. Thick as thieves, robbing the public blind with their salary demands. What gives them the right to make their ill-gotten five-figure salaries when the typical American struggles, yes struggles, to pay for all of those cool features on their cell phones?

It’s a scandal. Until we address nurse’s pay health care will continue to get more and more expensive.

And don’t even get me started on the respiratory therapists, pharmacists, and others who unfairly try to parlay their many years of education into the high wages thus forcing the sturdy peasantry to choose between their blood pressure medications and their personal watercraft.

Made of Money

On the subject of health care spending, it is fairly obvious to anybody who has spent any time in a hospital why our nation spends so much on health care. Just pick up a random chart from any nurse’s station and the chances are you could elucidate a medical history that reads like a pathology textbook. I used to be amazed that one person could have so many diseases and so many procedures. Now that I have grown used to Homo Polymorbidus I am more amazed at the rare patient who has no past medical history and takes no medications. Hell, even most kids are on something.

So it’s true that we spend a lot of money but keeping the typical ninety-year-old alive isn’t cheap and is only made possible by a stunning amount of medical care, the cumulative amount of which is probably in the millions of dollars. In one two-month stretch in the Emergency Department I saw the same nonagenarian three times for essentially the same complaint. The triage note said “Altered Mental Status” but it might just as well have said “The Nursing Home Panicked When the Patient Seemed a Little More Sluggish Than Usual.”

Folks, when you’re ninety you just start slowing down a tad, especially if you have been in a nursing home since the Reagan adminstration and sit at the pinnacle of the medical food chain as a top predator of medical services. That much medical care would wear anybody out. I am not advocating discarding the elderly. It’s just that somewhere in the feeding frenzy a point is passed where we need to step back and say, “What in the hell are we thinking?” We admitted the above-mentioned patient twice and as far as I know she has returned to her nursing home in the same mostly demented state that is her baseline and where she will lie, collecting bed sores, until the next time we save her life.

Now, one patient is not going to bankrupt the system. The infrastructure is in place after all, so what’s it going to hurt sending one frail little old lady up to the ICU? But that’s kind of the point. It’s the infrastructure that costs money, not the individual patient. Collectively, the ethos that requires us to keep everyone alive at all costs all the time requires that hospitals have a commensurate level of facilities and staff. It also requires an army of highly paid specialists to coax the last dregs of life out of the actively dying.

Is this a bad thing? I can’t say. When I was twenty I thought life was over at forty. Now that I have passed forty I can see that life is still worth living even if I can no longer run six-minute miles. Maybe despite being a doddering wreck at eighty I won’t be ready to shuffle unselfishly off of my mortal coil so as not inconvenience my children. But keeping me going will cost money. Everything that requires time and resources that belong to somebody else does. The expectation that it can be otherwise is ridiculous, as is the religious faith of the Single Payer zealots who believe that by adding an expensive layer of ineffectual free primary care somehow everything is going to be all right.

In no way is any socialized, quasi-socialized, or we-swear-it-aint-socialized scheme going to do a thing to lower the cost of medical care unless fundamental changes are made in the way we conduct health care business. As these fundamental changes mostly involve the rationing of care for people who expect limitless access, the voting public is never going to buy it unless they are tricked into it with promises of a shining all-you-can-eat medical buffet on a hill. This is a promise that cannot possibly be kept except by continuing to increase health care spending. After all, what politician has the guts to tell the people that they can’t have it all? To do so is counterproductive anyways, even for an honest politician of which there are many, because it is political suicide. No one is going to bell this cat.

What Are We Really Getting for Our Money, Anyways?

I’m not entirely convinced that a lot of what we do on a routine basis is really worth the money. Take a simple thing like Coumadin. Coumadin inhibits several of the factors in blood that makes it form clots. The lay people call it a blood thinner (although it doesn’t really make blood any thinner) and some even know that it was first used a rat poison.

Coumadin is widely prescribed for all manners of conditions, particularly for atrial fibrillation to prevent clots from forming in the dead spaces of the quivering left atria. Pieces can break off of these clots and travel to practically any organ in the body where they can abruptly shut off blood flow. In the brain this is called a stroke and is a particularly deadly complication of chronic atrial fibrillation.

And yet coumadin is not a benign drug and can cause complications every bit as bad a stroke. The interesting thing is that without coumadin, the risk of forming an atrial clot a stroke is about six percent per year. Just taking aspirin, a relatively safe drug that “thins” the blood by preventing platelets from clumping together, lowers your risk to three percent per year. Using coumadin lowers the risk to one percent per year. So you see that not only is the risk of clot formation stroke in atrial fibrillation fairly low to begin with but to achieve an almost insignificant reduction in risk we habitually pick a dangerous drug that is likely responsible for billions of dollars worth of side effects over a the safer drug.

That’s kind of the gestalt of American medicine. The drive to spend whatever it takes to extract the last bit of life out of everybody even though we are already well into the realm of diminshing marginal returns for a large portion of what we spend.

Curbing Health Care Spending, Belling the Cat, and Other Dangerous Activities