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Sep 11, 2008

ER Medicine and Bureaucracy

A Specialist in Emergency Medicine Leaves His Job

This is an extension of a comment I made to What Will Obama-Care Mean For You? at AdviceGoddess.

A board certified physician in Emergency Medicine made the posts below at blog "M.D.O.D". He is leaving that practice because of the waste and bureaucracy imposed on him.

My summary:   Medicine becomes more expensive, harder to do, with worse outcomes, as government imposes intrusive regulation and arbitrary quality measures, despite any good intentions.

Future bureaucrats might want to be doctors. Maybe they can satisfy this desire by being healthcare managers and accountants. Certainly there are few people of quality who will become real doctors, after doctors are placed at the lowest level of some government agency. This has bad implications for the increasing view that medical care should be an extension of the government.

Here are a few of this doctor's posts that I found interesting, with excerpts. There is much more there.


Reasons I'm Leaving Emergency Medicine #1 - My Non-Labor Day   08/31/08

"We stick people with huge needles, we do minor surgery, we occasionally do major surgery (but always fail as cracking someone's chest open in the ER rarely works to get someone fixed and eventually home), we jump-start hearts with thunderous doses of electrical current, we break terrible news, we pronounce babies dead, we pronounce old folks dead, we save lives, and we make mistakes."

"The thanks are few these days given the horrendous wait times and huge bills. I am caught between the realization that I AM, in fact, doing an important job, and the realization that my common sense solutions are NOT appreciated, and will not be implemented anytime soon."

Reasons I'm Leaving Emergency Medicine #2   08/27/08

"To me, medicine today is a turd because we call patients 'customers', try to do better 'customer service' with all comers, most of whom do not meet the traditional definition of 'customer' (ie someone who pays for their services), worship at the feet of a terrible unfunded mandate called EMTALA, and also worship at the feet of a bunch of worthless committee hacks called TOFKAJCAHO ("The Organization Formerly Known As JCAHO)."

Note: EMTALA is the Emergency Medical Treatment and Active Labor Act It requires that hospitals treat non-paying patients the same as ones who pay or can pay. JCAHO is The Joint Commission on the Accreditation of Healthcare Organizations, which sets standards of care and paperwork for accredited hospitals.

"We also shuffle money from the folks who actually gave more than a second's thought to their health to those who have made, and continue to make, poor decisions. In other words, there are tons of doctors and hospital CEOs and legislators who fancy themselves as modern-day Robin Hoods. They are not, they are the Sheriffs of Nottingham, but then again who am I to say, I think the thing at the top of this post is a turd"

"EMTALA has killed the best medical system in the world, and why? Because some douchebag legislators thought that it would buy them votes (and they were right). I also know how to fix our mess, but, since I major in plain-talk, I will never be elected, nor will anyone who says this, and here it is."

Reasons I'm Leaving Emergency Medicine #3   08/19/08

"I wanted, within the walls of the ER, to be in charge. I figured that, being Board Certified and subject matter expert would allow me to be benevolent King in the ER. Oh how wrong I was!"

"The real power in medicine today and the ability to effect meaningful change is not vested in practicing physicians. It is vested in the clipboard carriers... the makers and enforcers of policy and procedure, and the 'owners' of the 'business'."

"Example: Three years ago at my current institution the method for performing urinalysis was changed from the simple dipstick method (with dedicated lab confirmation and culture when needed) to the whiz-bang (nice pun eh?), can't miss, lab-run urinalysis."

"Besides being a huge waste of money, this extended patient stays in the ER for no good reason, as the lab UA takes longer."

How to be Annoying and Useless:
An Introduction to JCAHO and Press-Ganey

04/06/08 at DocsOnTheWeb by EtoTheIpi
A doctor complains about bureaucracy imposed for no real improvement:

"Hmmmm. Self-serving? Annoying? Chock-full-o-'business-speak'? Oh yeah. If they were just merely useless that would be OK, but these f**ksticks have literally changed the practice of medicine by putting up continuous blockades to the delivery of care: fill out yet another form; 'accredit' yourself to wipe shit on a card and see if it changes color; answer to clipboard carrying nurses if you don't fulfill your core measures; and on and on"

"Now, Press-Ganey. This is a survey company that asks patients to respond to questions about the quality of care they received. Really it is the perceived quality of care measured, often from non-paying "customers", who demand perfection and know very little about medicine (a hospital, by the way, is not a hotel. Sorry.) A 'mean nurse' can [ruin] your Press-Ganey scores relative to other hospitals. A doc who says "no, I know better" to an annoying patient will drop to the bottom of the list."

"Control has been handed to the paper pushers and taken away from the doers. I weep for our profession."

ED Discharge Instructions
09/16/08 - at WhiteCoatRants
Another Emergency Medicine physician reports mind numbing bureaucracy and ignorance about the realities of practice.

"It’s not enough that we explain the discharge instructions. It’s not enough that we provide written instructions for later review. Now we have to set up a classroom in the back hall to make sure that all patients, regardless of their neuron density, fully understand everything that they have been told. Great. What’s next? Extended admissions with intensive courses in operant conditioning and english as a second language so patients can “understand” what they have been told?"

Never Events
10/02/08 - Medicare says some events should "never" happen. When they do happen, you will probably pay for them. Via WhiteCoatRants- The Beginning of the End is Upon Us.

Healthcare Is a Right (and Free Puppies) [WebSite]
10/15/08 (10/09/08) - M.D.O.D  (quoted with some edits)

Physicians suspected when EMTALA was passed that it was a set-up for a government takeover of health care in America.

[ EMTALA is the Emergency Medical Treatment and Active Labor Act. It requires that hospitals treat non-paying patients the same as ones who pay or can pay. ]

The sub-prime meltdown is EMTALA writ large on our economy. The government forced [or made it profitable for] banks to provide mortgages to people that would not otherwise have qualified (Five Million Illegal Mortgages). The "genius" solution is to get the government more involved.

Since Obama has declared health care a 'right', let me explain what will follow if this "right" is given even a firmer foundation than in EMTALA.

1. Care will be rationed. It's just that simple, all the other consequences are obvious, but this is the most important
one for you.

2. Physicians will quit, retire early, cut their hours,
or otherwise opt out.

3. The rich will still get excellent care either legally or illegally, but it will be unavailable for ordinary folks (see #1).

With a 'right' comes a 'responsibility'. If health care is a 'right' then who is responsible for it? For the last twenty five years the answer has been the taxpayer, physicians, hospitals, and insurance companies. The system has nearly broken under its weight.

I will make more money, initially, with an Obama-like plan, and I will not work as hard. It is idiocy. For many of you who are fairly healthy it will be great.

When you get really sick, however, you will wait. Depending on where you live you may wait till after you die because there will be no incentive for hospitals or physicians to see more patients or to expedite treatment. In fact, if tort reform is not enacted along with Obama-care, it will be a really bad idea to see more patients than your banker's hours allow, and a disincentive to take on difficult cases.


Jerry Pournelle calls Kaiser
10/09/08 - JerryPournelle.com

[edited] I have spent the morning on the telephone dealing with the Kaiser phone tree. Kaiser human beings are extremely nice, and most of them are very competent, but their phone tree system is maddening. I think of it as a preview of national health care under Obama: replace all the nice people at Kaiser with civil servants who consider themselves underpaid, and continue the phone trees.

That was with Kaiser, which is an extraordinarily well run organization -- at least in my experience -- and staffed with some of the most pleasant and just plain nice people I've ever run into. Now imagine this experience when it has all be nationalized and there's a big national health care system. I can hardly wait.

Pennsylvania Is Driving Its Doctors Away
10/25/08 - WSJ.com by Dr. Frederic Jarrett, a vascular and general surgeon, and Clinical Professor of Surgery at the University of Pittsburgh. [Edited]

High malpractice premiums were (and still are) driving doctors out of Pennsylvania. So Pennsylvania created M-Care insurance to pay extra-high malpractice awards, and made doctors pay only part of the cost. The money came from a $500 million fund from cigarette taxes. Previously, malpractice premiums were sometimes 55% of specialist income.

M-Care helped, but not enough to stop a downward trend. Younger doctors are not willing to locate where liability payouts are twice the national average and physician income is 44th of the 50 states. The number of practicing physicians is down 6% in the past few years, and 20% of licensed physicians are not caring for patients. In 1992, 60% of residents stayed in Pennsylvania after training, compared to 20% now.

The current Governor Ed Rendell is now desperate to create a universal health-care program, to win a cabinet post under Barack Obama. He wants to cover people up to 300% above poverty level, funded by the cigarette money. This means raising the M-Care premiums and squeezing doctors to pay for skyrocketing malpractice awards. My total liability premiums increased 40% over what I paid last year, when the M-Care portion was abated.

Pennsylvania's physicians are willing to provide health care for those who can't afford it. More than 90% of us accept Medicaid despite reimbursements that are obscenely low and have not been raised since 1989. But, other doctors and I object to being extorted to fund the governor's socio-political agenda.

If you are a woman with a high-risk pregnancy, you may be unable to find an obstetrician in the rural areas between Philadelphia and Pittsburgh. You might not find an emergency neurosurgeon in the two-hour drive between Pittsburgh and Erie. Call Mr. Rendell about his plans to "cover all Pennsylvanians."

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