Dec 18

The Bullshit Doctors have to Deal With (Part one)

Got paged in the middle of the night last night.  1:13 a.m..  Sgt Darby pages me: (Yes I too am surprised to get paged by a Sgt- very unusual, maybe the first time it’s happened) “Yeah, uh we were just calling you from the security office here at the hospital because we let your colleague use the keys
to the shred box earlier today and we just realized he didn’t return them.  Do you know anything about them?”  My response: “No.”  My thought: Are you f-ing kidding me? It’s 1:00 am and you’re paging me to find a key you gave to SOMEONE ELSE 8 hours ago?

Dec 05

Why Insurance is the Devil

This is a book, not a blog post, so I’ll have to make it really simple.

Doctors would love to get paid in cash.  LOVE it.  At some point, the government said to doctors who love cash – we’ll guarantee you payment from a certain subset of patients who have difficulty paying their bills (Medicare) and doctors thought, “Gee, this is great – we can have some patients pay cash and the ones who can’t because they are old and retired, they can pay too.  Awesome.”

In come third party insurers who basically made the same deal for everyone else and that was awesome too.

Where it falls down is that insurers don’t want to pay doctors.  They would be happiest if they never paid a penny to any physician.  In fact, their contracts work in discounts to physician fees.  If I bill a cash patient $200 for a visit, the insurance company will negotiate the fee down to around $100 or less.  Now, what if I want to say that cash patients can then pay the same thing?  No.  That’s illegal and violates the terms of my contract with the insurers.  They won’t allow me to see cash patients for free or at a discount.  I have to charge them my full rate schedule or the insurer can drop me from their plan.

So, doesn’t that mean that healthcare is more expensive for uninsured patients?  Yes, it means exactly that.  In fact, it’s worse at the hospital where uninsured costs are up to 10x the cost of the insurance contract.  Cheap insurance plans – with high out of pocket max and deductible – are pretty much negotiated rate plans and don’t actually pay a lot on your behalf.  That said, even cheap insurance is better than “going bare” because you get insurance prices for your health care even if you are the one footing most of the bill.

That is the evil genius of the Affordable Care Act.  It really doesn’t do anything to change the underlying structure of the relationship between insurance companies and physicians.  Moreover, it pushes patients into insurance coverage that probably isn’t worth as much to the patients as it is to the insurers.  Do you think that insurance companies hate the ACA?  Negative.  They LOVE IT.  It is the best thing to happen ever to the most corrupt industry in the United States.  I mean, the scandal where they dropped 1 million individual policies recently…that was great for them because individual policies don’t allow them to diversify their risk like group policies do.  They would rather those people go into the exchange where, if the sickest people cost them more, they just have to raise the rate $10 a month each on 100,000 people and they make enough money to cover their losses.  You can’t do that with individual policies.

Of course this site is about doctors, not insurance companies, so recognize that it all goes back to your doctor wanting the phat cash.  If your doctor was willing to see you for cash and didn’t deal with insurance companies, you would probably end up paying less over all and you might even get more satisfaction out of your healthcare.   So…fuck doctors.

Nov 05

Revisiting Neurologists

I recently included neurologists in my “Top 9 of Stupid Doctors” because they don’t really do anything from a treatment perspective and instead diagnose patients with diseases that cannot be treated.  I want to present on a particular aspect of Neurology that is perplexing and also points out why doctors should not be salaried by hospitals if you want quality care.

So a particular hospital in my area has a contract with a neurology group that very specifically outlines what they do and don’t admit to their own service.  For the most part the agreement is such that they will consult on almost any patient – stroke, Guillan-Barre, seizure disorders, you name it.  There is only one condition that they have to admit whatsoever based on the rules (the rest go to hospitalists and they consult).  That is – “Status Migraine”.  That’s a condition that’s rare and difficult to categorize, but essentially is a migraine that is refractory to treatment and won’t go away.

And it so happens that one walked into the ER a few weeks back and the hospitalist was called (because they admit 99.99% of neurology admits) and the hospitalist says, “Wait, this is status migraine” and correctly calls the neurologist to admit.  Well, after a long discussion the neurologist says, “I don’t really think that’s status migraine, you just admit and I’ll see them in the morning as a consultant.”  And so the hospitalist just admits the patient – no use fighting that battle in the middle of the night.

So the patient is admitted and the neurologist sees them in the morning.  Says, “Looks like status migraine.  Discharge patient home, no indication for admission.”

Now, this may seem like a tragedy from the hospital standpoint, but really it’s great.  The hospitalist sees the patient, bills a high acuity admit (they are all high acuity, and bill out around $300 or more for the physician fee).  Then the neurologist comes in, sees the patient, writes a consult note, and bills another $300.  All that money gets taken in by the hospital.  You see?  Two physicians see one patient for double the money, and no one really did anything to help the patient except argue about them and then discharge them home.

Oct 28

Just a Reminder

I’ve been overwhelmingly busy.  Ever since I started this blog and really started being a complete asshole to everyone – you know, just being very self-righteous and full of myself – my practice has really taken off.  Therefore, I haven’t had the time that you all want me to spend on giving it to medicine in the United States.  I feel compelled, however, to note a few things:

  1. Doctors are ridiculously stupid.
  2. Most physicians are motivated primarily by money.
  3. Nothing will change these facts until people educate themselves about how the medical marketplace works.

Okay, there is a potential discussion.  The socialist demagogues who run this country think that you can regulate a free market and turn it into something controllable.  But the complexity is too much to bear human controls.  Healthcare is so extremely regulated by different parties that want their cut, that the actual dollars spent on healthcare that go to make you better are…a MINISCULE percentage of what is actually laid out on your behalf.  And it all goes to feed a bureaucracy that does no more than add complexity and cost without providing an enhancement to the benefits you expect.

Does the bureaucracy keep your doctor from doing unnecessary procedures and raking in the fat cash?  I can tell you…no.  Does it provide you a safer and cleaner environment of care?  Pretty sure the answer is no.  Does it make you feel closer to your physician and give you the more personal relationship you feel you deserve?  Uh…no.

Medicine is so fucked up that it is truly, like many things in this country, beyond any hope of repair.   And who is to blame?  That sweet old doctor that used to come to your house with a black bag.  He’s to blame because he sold out to the insurance company 50 years ago and sold you out along with him.  He bought into Medicare and turned the practice of medicine from an art into a business.  Your doctor is a whore and the hospital is the brothel.

May 14

The Doctor’s Lounge

DoctorsLounge_rev1

Take what you like from the People’s Lounge. Obviously all wealth and privilege is undeserved.

I’m going to shift gears briefly and talk about how stupid other people in the hospital are besides just the doctors.  There is a place called the “doctor’s lounge” in the hospital and in general, this is where the doctors go to get a coffee or a muffin in the morning or watch some TV and not be bothered by bitchy nurses or pathetic patients.  If I was a member of John Q. Public (rather than the best doctor on earth) or even if I was say a nurse, nurse tech, or ward cleark, I would probably NEVER GO IN the doctor’s lounge, and I think most of you are the same.

That’s actually not how it ends up working out.  It seems like every worker in the hospital makes daily visits to the doctor’s lounge to grab something.  I’ve even seen the custodian sneak in and grab a cup, leave, and fill it with water from the water fountain.  And I think that’s no big deal really, but when everyone in the hospital just kind of filters in, gives a sheepish look, and grabs whatever they want – it’s not really the DOCTOR’s lounge, is it?  It’s the PEOPLE’S lounge, it’s like a microcosm of socialist revolution in MY corner of the hospital.  And it really comes down to our willingness to defend it.  No doctor wants to be the one that says, “Hey, you, bootscum.  Don’t come in our lounge, stay the fuck out.”  Because we are way too nice for that.

So as a related anecdote, there is one particular repeat offender in my current hospital who comes in EVERY DAY, gets a cup of our Starbucks coffee and leaves and always says something like, “You guys have the best coffee”.  Note, it’s not “This is the best coffee” or “I’m so glad we get to share this.”  It’s very poignantly – “This is YOUR coffee, and I’m TAKING it.”  And so this lady I think maybe it’s just this one thing.  But no, I go to the grocery store, get 9 items and feel a little guilty about being in the express lane because I’m so close to the 10 item limit.  But I’m waiting behind this lady with about 80 items in her basket and GUESS WHAT?  It’s the same doctor coffee stealing lady who is now stealing the general privilage of the express lane.  Some people will take anything that no one is willing to defend.

May 10

Doctor Words, Part 1

Doctors have to use a lot of words that people don’t understand, such as “Carotid Endarterectomy” and “Necrotizing Fasciitis” and they tend to add specificity to our meaning and can be translated into the language of mortals without too much trouble.  In fact, when you’re a medical student (by you, I don’t mean most of you, I mean genius doctors in training), you are encouraged to use these doctor words, and berated when you don’t do so.  I could care less about this subject, that is not what this post is about.

The doctor words I mean, are the ones that seem like they are in your language, but actually are rather complex, nuanced phrases that have a hidden and sinister meaning that you are completely unaware of.  Qua:

  1. “We’ll see what the [name of test] shows”.  In the ideal world of doctoring, physicians come up with a list of possible diagnoses, narrow it down based on clinical symptoms and signs, and then pick a test or two in order to pinpoint the diagnosis, and then treat the patient.  That is the executive summary of what a doctor is supposed to be.  But more and more, physicians get a nice cloudy ballpark view of the diagnosis and then hit it with the ultimate test of all disease- the CT of the Abdomen and Pelvis.  The above phrase really means, “I have no idea what’s wrong with you and thus have no way to guide your expectations, form a cojent continency plan for different outcomes, or give you any sort of comfort or counselling at this time.  I, in fact, am a little scared that if the CT is negative that I’m going to have to refer you to the University Hospital.”
  2. “It’s probably just scar tissue from surgery”  This is a response to the question of why you have persistent pain at or around your operative site after a procedure.  No one ever thinks about the scars they have on their body and wonders why they don’t cause daily, excrutiating pain.  Instead, they think, “Yeah, doc is probably right.  No way that he cauterized my pudendal nerve accidentally causing crippling neuropathic pain.  Scar tissue has to be it.”  Of course, in fairness to your lazy, shithead doctor, there really isn’t much to be done about it.  Except sue the fucker.
  3. “You should ask your PCP about that.”  Primary Care Physicians are demonized by all specialists for not understanding their specialty.  But when it comes to anything NOT in their specialty, suddenly the PCP is the only one that could possiblly know the answer to the patient’s question.  What this phrase really means is, “I know the answer because I got a 255 on my USLME which your PCP couldn’t hope to do in a million years.  I, however, can’t be bothered to help you with that because I don’t have time, can’t bill you for knowing the answer, and really have had about enough of your bullshit whining.”

Real douchy doctors can combine phrases like this into new and completely deceptive statements:

doctor words

You know, your pain could be caused by scar tissue from the surgery, but we’ll know more after the CT. Have you mentioned this to your PCP?

May 08

9 Stupidest Medical Specialties

I’m taking a hint here from the pros of the internet, and I’m releasing my “top 10″ list of stupidest medical specialties.  Ok, so there’s only 9.  That’s the number, the number is 9.  We can hold a vote for the 10th I guess.  Maybe later I’ll release the actual stupidest individual doctors but that could also land me in trouble I think.

 medical specialties

Click here for the list.

Just as a side note, I want to say that this site is approaching it’s 1 year anniversary, and as such I am beginning to hear rumblings that my fans are planning to throw me a party.  In regards to that rumor, I want to say thank you heartily and bring it on!

Apr 22

You Aren’t Sick

Do you remember a time when you went into the doctor when you felt sick, the doctor told you what was wrong, and maybe gave you medicine or (oh no!) a shot and then you got a sucker?  Yeah.  Because you were a kid and that’s what pediatricians do.  They see kids who are well once a year to make sure they stay well and then when the kids are sick they make them better.  I generally think pediatricians are a good kind of doctor.  Guess what.  They are the LOWEST PAID DOCTORS in America.  So no one wants to be a pediatrician, even if they like kids.  Why not be a pediatric cardiologists or pediatric surgeon…people who make the dough.

Nowadays, the job of the doctor is to convince you that you are sick when you actually feel fine.  Right?  High blood pressure, silent killer.  We have a pill for that.  Diabetes type 2, huge epidemic.  We have pills, glucose test trips, and shots for that.  Hyperlipidemia – can cause you to get coronary artery disease right?  We have the single largest selling class of medications for that – statins.  Now.  What are we doing for you?  Lets reviews:

First, hypertension.  The goal of blood pressure management is to prevent “end organ damage”, specifically damage to the small blood vessels in the kidneys, heart, eyes, and brain.  Blood pressure has effects on every organ system, but those are the most sensitive to long term hypertension.  Do we prevent heart attacks by controlling blood pressure?  No.  Blood pressure control alone, isn’t enough.  According to Dr. Granola (pussy) you have to change your “toxic lifestyle”.  Whatever dickhead, blaming the patient is the oldest trick in the book.  Anyway, he’s right.  The drugs we’re selling to you aren’t helping.

Okay.  Diabetes.  So we do know that keeping your blood sugar under “good” control is important to slowing progression of the disease.  If you have diabetes, then you are at risk for renal failure, stroke, amputations, heart attacks, and blindness.  To name a few.  So, which is worse?  Having an amputation or having to stay on a strict diet and have insulin shots?  According to this study, they are about the same.  That’s right, a bunch of diabetics who actually HAD an amputation said that the bother was about the same as being having strict glucose management.  Having a mild stroke was actually considered more favorable.  Yeah, we can manage your disease, but you’re going to hate the cure more than the disease.

Hyperlipidemia.  That means high cholesterol and/or triglycerides.  Statins – the most prescribed class of drugs, a group of companies who have their dicks so far up the ass of the AMA and AHA and each individual cardiologists that they can pee right of their mouths – that group of drug DEFINITELY lowers cholesterol and lipids.  And that prevents heart attacks, right?  Well, in this meta-analysis of of 11 previous works, including 244,000 patients who had high cholesterol but no other problems, it didn’t appear that statins did anything to prevent death due to heart attack or any other cause.

So there you have it.  Your doctors are finding the diseases that will kill you, they are prescribing expensive therapy, and they are doing nothing to really help you.  Except make you feel miserable.  That probably makes you feel mad as hell.  But really, screw you, because I’m the one with $150,000 in med school debt and no real purpose in life.

Mar 29

Immigration

I want to take time out from talking about how awesome I am and how doctors can eat shit and die for a moment to talk about a current event.  Immigration.  I saw some black guy on TV talking about immigration (turns out he’s the President of the USA) and I actually agreed with something he said.  I haven’t seen the details of this plan, but lets get serious.  If immigants aren’t welcome in this country, then all of the white people and asians and african americans that make up like 99% of the population need to GTFO.  Because everyone here – whether by choice or in chains – is an immigrant except for the small minority of peacepipe smoking, firewater chugging native americans who didn’t die of smallpox and syphillus.

So we build this big fence and want to keep people out why?  Because they are taking our jobs?  Well…according to this guy, there are plenty of jobs – American workers just won’t do them for what the “going rate” is.  Now, in reality, the amount of money you get paid to pick oranges, apples, tomatoes.  So the guys in that story are immigrant workers who don’t get paid by the hour – no minimum wage to worry about.  They get paid by the basket of tomatoes they pick and so they work hard, get paid what they feel is fair (and probably is), and do you think they worry about the bigger picture of what undocumented labor is?  These are simple people!  They just feed their family and live in a country with nice things and good services. 

They don’t feel like they are mooching.  After all, they do put food on your table for a price under what it would cost to get fat lazy Americans to go and pick your food off the vine for you – and in the big picture, who is to say that the net benefit of cheaper goods and services due to an undocumented, low paid workforce is not worth the tax losses to government that have to be “made up” by good, clean-handed, “hard working” Americans.  Think about it.

So there’s that.  But of course, people feel this intense patriotism that doesn’t exist in other countries.  No one really flies the French or German flag on their place of business in those countries like car dealerships do here with the US flag.  French and Germans (with the exception of their massive, growing muslim minorities) have lived in their countries for centuries and although there ARE anti-immigration movements as fierce as ours, their countries weren’t BUILT on immigration.  The statue of liberty, one of the most beloved relics of American patriotism says on it, “Send me the shit off your boots and we will scrape it off and make shit casserole and celebrate” (that’s a loose paraphrase).  And so…why do these flag waving, gun shooting, hand fishing hippocrits want to ship out all of the potential immigrants?  Do they presume that it’s EASY to follow the letter of the law with regards to immigration?

You see, people THINK you can just call in and say, “Yes senor, I’d like to work on the tomato farm for Farmer McDonald and make an honest wage, tend his cattle, pleasure his wife, and pay taxes” and since NO ONE ELSE in this country is willing to do the work, they should say yes.  But because joe public thinks that these individuals want their job, there’s an outrage against allowing an influx of low wage workers.  Ugh…my head hurts.  The minimum wage is a problem, the aversion of typical americans to manual labor is a problem and so it creates a gap where undocumented workers fit perfectly.  Anyway, so even though businesses want the labor, the labor wants to come here, immigration actually refuses to allow them to come legally.  And so they come on the snide and are treated as criminals.  Next time you eat a tomato, just think about who probably picked it for you. 

 

Mar 28

Hospital Employed Physicians

Think about how medicine came about.  There was a person in your village or tribe who, when something went bad you went to them and he/she evoked the power of the gods through prayer, chanting, herbal remedies, or crude surgery in order to bring about cures.  This was before the randomized, controlled trial was invented, so really we can’t say if this was effective or not.  But this was the way of things, there was a healer, who was also a holy person probably.  Then at some point there came a decision that people should go see their healer in a specified place, sometimes a temple, sometimes what we might now call a clinic.  And later people would stay in these places where the healers dwelt and they become hospitals which really started to come on around the end of the 1800s.  Doctors starting having their offices elsewhere and when you got really sick, they’d put you in the hospital, but often times the doctor owned the hospital or he and his partners did.

Then the whole thing got big and out of control and now doctors aren’t even allowed to own hospitals even though it was our idea to make them in the first place.  It reminds me of the movie “Tucker” though when The Dude gets voted out of the presidency of the company that he created (a nice film on crony capitalism if you get the chance to waste 2 hours).  So there was a time when hospitals existed with doctors as sort of free agents bringing in patients to one hospital or another, but having privilages at other hospitals to change it up now and then.  That time is passing.

Hospitals make a lot of money off of lab tests, radiographic imaging, operating room utilization, bed utilization, and ancillary services (a word for “everything else that supports the main operation”).  But hospitals know that they can’t use those services unless a physician orders them to be used.  Trust me, if they could get around that they would.  So they are willing to give some of the profit from those services to the physicians in order to guarantee patients will use their hospital instead of someone else’s.  The other issue aside from that is that hospital payment is tied more and more to certain “quality” measures which in the end rely on the compliance of the physicians with the quality standards.  And trust me, many physicians see quality measures as pure and simple bullshit (largely they are, more later).  Hospitals employ compliance and quality officers (nurses who are burnt out on cleaning shit out of bedpans) in order to boost their numbers, but ultimately they need the buy in of the physicians.

A physician who sees patients in the hospital full time and bills E&M codes (evaluation and management – what we get paid for seeing you, talking to you, and making you turn your head and cough) and does very few procedures will work hard and net between $150 and $200,000 a year, and that’s really busting their hump.  The hospital can offer them somewhat more than that and guarantee a shift-work like schedule with bonuses and incentives tailored to the hospitals quality measures.  They get a good salary, the hospital gets a compliant employee, and what’s more the hospital gets all of the patients the doctor would see to come to their hospital.  Also, the doctor becomes a “brand” that the hospital can market to patients as an expert (which benefits both hospital and doctor).

This is great right, everyone is happy, right?

Here’s why it is the end of civilization:

1.) Work Ethic – Being a doctor is hard.  Traditional wisdom says that when you try to take something hard and make it easy that something gets lost.  Why does handcrafted furniture command better prices than those made by machines?  You sit on them just fine, they may be aesthetically pleasing, they do their job.  But nothing more, they have no soul, no character, no passion.  And that applies to physicians who do the 9 to 5 thing.  It takes everything about being a doctor and makes it sterile (not in the good way) and passionless.  Getting a salary to work a certain number of hours regardless of patients seen, etc is a way to make doctors feel like their work is unimportant.  Underworked doctors will become entitled and lazy.  Overworked doctors will burn out.

2.) Specialists – Hospitals want to market their specialists.  Primary care makes no money for the hospitals.  They don’t operate, they don’t order high volume tests, and the diseases they treat opreate under “DRGs” which determine payment before the patient is ever treated – so the incentive is to do less for the patients.  But specialists make a lot of money because the opposite is true.  The more they do, the more they get paid – and the money goes to the hospital.

But specialists come in varying quality and ethical standards.  The ones that take the big dough are the ones that didn’t want to have to work in the community to get their own consults, build up a reputation among their colleagues, and climb their way up into the money.  They decided to suckle the fat teat of the hospital in exchange for easy referrals, easy hours, and a fixed call schedule.  Again, that sounds nice.  But if they don’t get paid to see an emergency patient, maybe they won’t come in at 9pm to do so…admit, wait until morning.  Raise your hand if you know someone who was admitted to see the specialist in the morning.  Does that sound right?  And then if it isn’t an emergency, if its a matter of convenience or courtesy, that doesn’t exist in the employed model.  If you know you get the referrals from the hospital, why show extra courtesy and stay late or come in on a weekend or during lunch to see a patient as a courtesy to a colleague.  You don’t have to show off!  The check’s in the mail, baby!

Finally, the hospitals market these guys like crazy, but they aren’t usually the best physicians in their field for the above reasons.  The good ones are out there making mad cash and working really hard.  So your media gets inundated with b.s. about the best people providing the best procedures and it is all untrue and so you suffer.  Think this doesn’t happen?  Read this.

3.) Prison - Not like federal jail, but like the hospital is a prison for physicians.  They sell their practice to the hospital literally.  They sign over their insurance contracts and medicare benefits to the hospital and then promise that they will not compete against the hospital if they leave.  That means most of the time that if they leave, they can’t practice medicine within like 50 miles of the hospital for 5 years, or maybe even 1 year.  They can’t call or write their patients to say they are leaving and they want to remain their doctor.  The hospital has them, the doctor is now just an agent of the hospital.  It doesn’t matter if the time lapses and the doctor comes back and practices there legally, the patients now have new equally douchebaggy doctors and they aren’t switching back just because you got a conscience and stopped being a medical whore.

4.) Buying in to Quality – I believe in quality medicine, but in our police state of hospital care, it is defined somewhat arbitrarily based on unproven standards.  You can prove that in a subset of patients who have CHF that discharging them on an ACE Inhibitor or ARB is good for them.  I don’t argue that.  But forcing the whole world to do it and then calling that quality medicine – making it one of like 10 standards by which all quality is measured…what does that do?  I don’t know, and no one does.  Quis Custodiet Ipsos Custodes my friends.  In other words, how do we know that this massive quality measure is actually going to improve healthcare.

Aside from picking arbitrary measures and deciding that’s what quality healthcare is, what about, oh, say, meeting the expectations of the patients?  I mean, hospitals want you to be happy and come back for more tests, surgeries, etc.  BUT they don’t care if you’re really truly satisfied or have gotten an excellent outcome.  What I’m getting at is that what if the whole quality effort is completely misguided and won’t really make patients feel happy, feel trust for their caretakers, and have a sense of health and wellbeing, isn’t that what it should be about?  For instance: doctor_cares_comic

Is that quality healthcare?  The government thinks so.  And so does your hospital employed physician.

So, I know, TLDR, but to sum it up:

Doctors are all stupid and lazy, BUT

Doctors who work for the hospital are the true whores of the medical system.

Thank you, that is all.