Jul 23

Socialized Medicine – The Road to Totalitarianism

Markets cannot be controlled.  They can be influenced by regulatory action, but they cannot be controlled.  Medicine relies on several government points of influence that existed long before the Affordable Care Act.  To practice medicine, I have to be licensed by the state I want to practice in, which is a very arduous and involved process.  Although in general it is difficult to lose my license, without it I cannot legally practice.  Just thinking about that fact causes me some fear.  I have no asset that has any value that generates money – like a machine, a store, or a piece of property.  All I have is my knowledge and expertise which, if the government wishes, I can be prohibited from using.  Permanently.

I drew this myself.  It took 5 times longer than writing this post.

I drew this myself. It took 5 times longer than writing this post.

Hospitals are the same.  In order to have a hospital, it must be licensed to operate and is held to very rigid standards.  Hospitals are in less of a bind because the right to operate belongs to the owner of the hospital and if lost, they can transfer all of the assets to a new owner who can resume operation after a period of review. 

Now, it seems like this level of regulation should lead to a very regiment system whereby the controls in place produce a very predictable result.  Nothing could be further from the truth.  In fact, medicine has the absolute lowest level of standardization of outcomes and practices of any major industry.  You can talk to several doctors and get completely different recommendations.  You can go to completey different surgeons and get completely different operations – and your outcomes may range from tragic to heroic. 

Here is where the concept of equality comes in.  You see, with the ACA, supposedly all people now have the ability to buy health insurance.  As it turns out, it’s pretty crappy and reimburses physicians a small amount of what they feel they deserve.  Whether they truly deserve more or not is irrelevant.  At the moment, every physician can decide if they want to participate in a given insurance program or not.  And not surprisingly, the physicians who can name their price for an operation are not interested in taking what amounts to, in many cases, a 1000% pay cut in order to treat people with crappy exchange plans.  Do you have options with your exchange policy?  Sure.  You can go to the guy who no one else wants to see.  Who routinely botches operations, abuses his physician privilege, and knows that you have no other choice.  His waiting room will stay full of desparate souls because he is the only game in town. 

This is what many opposed to ACA are calling the “two-tiered system” or “multi-tiered system” because while some physicians will be able to demand cash for an operation and may give superior results, other less skilled physicians will give poor results.  What those pushing for government paid medicine fail to account for is that you cannot encapsulate the market.  You cannot create a world where you control the product you are paying for unless you can successfully ensnare ALL factors that influence it.  The next logical step is to REQUIRE physicians to participate in whatever plan – at the cost of their medical license.  Many physicians will quit rather than be told how to practice.  So the next step witll be to REQUIRE physicians not to quit and to stay at their post.  You see where this is going? 

The attempt to control a market that many consider critical will ultimately fail unless the people of our country are willing to actually chain the participants to their “responsibilities” and force them to work for a wage that is considered fair.  To whom?  To the ones paying of course.  The ACA as currently structured will either fail or the attempt to make it work will destroy our country.

Jul 16

Dentists

If there is a hell (other than the one we all experience daily), then there is a special place there reserved for dentists.  This blog is about doctors, however I will make a special exception for dentists.  Why?  Because they call themselves Doctor.  In fact, dentists are more likely to correct you if you call them “Mister” than an M.D. is.  Why again?  Because they want all of the glory and none of the blame.  Although in our society it is now considered a right for you to receive medical care, there are certain parts of your body that are exempt – specifically those parts between your mandible and your maxilla.

Open your wallet and say “ouch!”

Because the government doesn’t regulate dentistry like it does medicine, dentists are pretty much free to do whatever they want.  First off, they bill you a lot of money to do pretty much nothing but tap your teeth with a piece of metal while they glance at their watch.  Second, although an ER doctor is obligated to treat your life-threatening condition if you show up – dentists are not.  Don’t think there are life-threatening dental conditions?  Think again.  Third, dentists have the ability to prescribe medications, including narcotics, and they do so with abandon. 

Dentists have the highest rate of suicide among individuals who call themselves “doctor” (followed shortly by anesthesiologists I add with no apology whatsoever).  That’s because they know that their lives are completely worthless.  They got into it for the money and found out it wasn’t as good as originally advertised, and now they are trapped underneath a practice loan that isn’t going to get paid for on their undergraduate “Biology” degree.  And so they look for novel ways to make money like doing breast augmentation on the side.  Because they learned to do that in med school, right?  No.  They didn’t go to med school, but they own surgery centers and have a surgical license.  So if they wanted to do your heart surgery, guess what?  They could.

At least they do a good job cleaning your teeth!  Oh wait.  Someone else does that with a vo-tech degree.

Jun 12

Rich Man, Poor Man…

Doctors sit in the uncomfortable spot of being “Upper Middle Class” in that, they make in the low to mid 6 figures, and occupy a prestigious position in common society, but lack much individual or collective power.  Doctors have slightly better cars, slightly bigger houses, wear slightly nicer suits, and eat slightly better food than the average individuals around them.  To say doctors are extremely wealthy by the standards of our culture and media would be hyperbole.

However.  When comparing what doctors have to all individuals, they become a very priviliaged, protected, and well compensated class.

Doctors will never willingly have to sleep here.

Look at this example of a lady who got fired from her minimum wage job for trying to show consideration for other blue collar workers in her community.  If a physician was in the same situation and gave say, free surgery to a firefighter to show support…even if the hospital was like, “Dude, please don’t operate on that guy for free…” he wouldn’t lose his job or his license, he’d get to give a press conference and talk about how great he is.

Physicians aren’t allowed to unionize by law.  But the law that forbids them to unionize also makes it very difficult to ever become a physician in the United States.  In order to legally practice medicine, you must pass THREE very difficult examinations and you must either go to a US accredited medical school OR you have to pass a fourth exam to prove that you speak English well enough to be a doctor here.  THEN you have do a residency program for 3 to 5 years to train as a physician.  Most hospitals now require board certification which makes it even harder to be a physician because you have to pass another test and in many cases two more tests including oral examination to prove you have what it takes to practice in your specialty.

That process makes a physician in whatever specialty he’s in seem like pure solid gold.  It’s not like anyone is just begging to replace him.  So when a physician decides to pork a hooker and in exchange give legal prescriptions for Xanax and Oxycontin…and then gets caught…probably he’s going to get a warning the first time, or have to go to a program to learn how not to be a criminal.  When the guy pictured above goes and breaks into a vending machine to get a Honey Bun because he’s starving, does he get special treatment?  Fuck.  No. 

Every time a doctor complains in my presence about how shitty it is to be a doctor and how things just suck so bad for us, it makes me want to grab them by the ears and puke into their open mouth.  Doctors don’t know how good they have it, and have the audacity to complain about entitlements in a world as fucking rotten as this one, with people dying of poverty and disease…things physicians have sworn to stomp out.  Fuck you you fat fucking doctors, you piece of shit whining whores.  You want to get paid more?  Start doing unnecessary treatments on people and using legislative measures to inflate your salaries.  What you already do that?  Pathetic.

 

Jun 11

Boys will be Boys

http://seattle.cbslocal.com/2014/06/09/doctor-accused-of-sexting-during-surgery/

TLDR?  An anesthesiologist was caught at his workplace (i.e. the operating room) sending lewd texts.  He was also banging nurses at the hospital and surfing porn using the hospital network.  And these things are being construed as a threat to patient safety.

This is both news and non-news.  The non-news part is that an anesthesiologist was fucking around during surgery.  They all do that.  They surf the web, they chat on their cell phone, they talk to anyone who will listen to them about their cars, houses, and ex-wives.  That’s not news.

The news is that this guy’s particular prediliction for distraction from his meaningless life was to look at porn and text pictures of his cock to his boyfriend during surgery.  In my mind, the story is that somehow this is worse than all of the other ways in which anesthesiologists distract themselves during surgery.  So…he’s “sexting” and putting patients at risk.  But the other anesthesiologists around the country sitting there reading Car and Driver (JUST as likely to jerk off behind the ether screen I might add) are NOT endangering their patients?  The story is that both of those guys endanger patients, but the poor sex addict guy is just doing it in a way that we say, “Ewww.”

I’ll be looking for the ASA to weigh in on this one.

May 29

See, I told you!

Here is EXACTLY what I talked about in my last post. Just want to make someone comfortable in their dying days? Don’t send them to the hospital…

http://sanfrancisco.cbslocal.com/2014/05/28/health-insurance-provider-denies-cancer-treatment-premium-mri-scan-tumor-sonoma-county-man-battling-cancer-denied-coverage-by-anthem-blue-cross-after-paying-100k-in-premiums/

May 22

What are Hospitals For?

I don’t talk about my own practice here much for many, many, many reasons.  For one, if I’m going to be a real jerk and say things that are very mean to physicians, I don’t want my identity to be known and I don’t want my patients to be involved.  But today I had an experience that really brought home what medicine in this country is about.

A lady walks in to see me in extreme pain.  Most of the time, people in extreme pain go to the ER and so it’s tough to see them in the office and figure out what’s wrong.  We don’t have pain meds, we don’t have a bed to lay in, we don’t have good vital sign monitoring.  But she’s clearly in pain, don’t need labs for that.  She had a history of cancer being treated and had no signs of disease last check, but now the area of her body in questions is so tender, she can’t be touched there.  But the exam is suspicious for tumor recurrence.

Now.  I know that if I admit her to the hospital, I can get her pain under control and put her on the schedule for a biopsy the next day and get it all figured out.  Fast, humane, efficient.  But as I’m coming up with this plan, knowing it is in her best interests…I pause and I think about whether or not her insurance would reimburse the stay and what I will have to say in my admission documentation in order to make sure no one disagrees with the admission.  The problem is that she isn’t acutely dying, doesn’t have a condition we can really make immediately better, and very likely will be readmitted in the future for the same thing (pain) meaning that the hospital may not be reimbursed for a second admission.

What’s the old lady? Are you hurting? Go home and take some morphine. Good thing they make it in pills now.

And it occurs to me that in all of this mental deliberation, what is lost is that the patient is hurting and needs the hospital.  What in the hell is that monstrosity of brick and mortar, mahogany wood panelling, and fountains, and pomposity, and self-importance there for?  Why is it standing as an eye sore in the middle of this city if not to relieve the suffering of my patient?  If they could do 100% boob jobs and cholecystectomies, why, they would.  They would bar my patient from getting through the door, I know it.

I mean to say that no one says, “Jeez, why are you bringing this hurting lady here, get her out!”  They all say that they want to ease suffering and cure disease from the hospital executives to the guy that cleans the floor.  And at the insurance company, same thing.  They all have mothers (maybe) and they all want the “best thing” for the individuals.  But these people aren’t treating individuals.  They are making decisions that impact the lives of hundreds, thousands, and in some cases millions of people.  And when you do that, you lose the ability to respond to the needs to the few, the suffering.  That is why the ethics of medicine will NEVER be able to coexist with the profit motive of business or the cost responsibility of government oversight. 

So there it is, there’s me being me and posting something that I care about.

May 11

Gynecologists Love to Spread Cancer

Gynecologists represent a subdivision of doctors that are neither really competent surgeons nor are they very competent physicians.  They stand in the nether regions between surgery and medicine.  Since most of the time they take care of very healthy patients – young women for pregnancy and screening for gynecologic cancer – they don’t get a ton of exposure to the sick, dying, and miserable.  The one thing they love to do above all other things is take out the uterus, and they want to do it without making an incision, basically for the vanity of the patient.

This is done by morcellation, which is a word I’ve really only heard applied to this practice.  It involves taking a bladed device and chopping up the organ internally to allow it to be squeezed through a tiny incision instead of making a large incision to take out the whole thing.  I’ve also only heard of gynecologists doing it routinely.  Other practitioners don’t do it because of the risk of spreading cancer.

Pre-morcellation

Post-morcellation, pre-Alpo factory

Most of the time uteri are removed for benign conditions like fibroids, or bleeding, or “da bitch just talk too much”.  Even in these conditions though, there is about a 1 in 400 chance of having a real cancer that wasn’t diagnosed.  And those whirring blades and the intra-abdominal meat grinding process can fling cancer cells all over the abdomen.  Suddenly a cancer that was going to be removed is now incurable.

So young women are being given metastatic uterine cancer through morcellation, other specialties are coming out against morcellation, the FDA is reviewing the process, there is an online petition to ban the process.  What to gynecologists say?

They say, FUCK YOU.  Essentially their response is that, whatever, our doctors are going to do whatever they want.  The idea that physicians need to ” communicate fully about the risks and benefits of all procedures” so that a woman can “make an informed and voluntary decision about the care that she receives” is the biggest bunch of hocus pocus bullshit ever.  Effectively their statement does not condemn, cast doubt on, call for more data about, or in anyway address the morcellation controvercy.  In fact, it’s a shit on the head of any woman who has metastatic cancer thanks to uterine morcellation because every physician has the duty to fully discuss the risks and benefits of a procedure.  Do you think they are going to do any better?  Do you think a gynecologist is going to change his practice to save one out of every 400 women he treats?  FUCK NO.

Doctors, especially gynecologists, are soulless fucks with no regard for humanity, no regard for safety, and absolutely a lot of interest in money, getting fat, and fucking children.  Okay, most doctors don’t fuck children, except figuratively, but that is another blog post.

 

 

 

 

May 01

PET Scans are stupid

Cancer is scary.  Really scary.  If you have cancer that is localized and it is removed, probably you will live.  If the cancer moves beyond its original home to somewhere else, then probably you will die.  This is the unfortunate truth of cancer.  Once you have had your initial surgery, doctors may do repeated body scanning to look for recurrent or residual disease.  In some cases there is an improvement in outcome if disease is discovered unifocally and removed or irradiated prior to further spread.

Mostly though, if you are found to have recurrence or spread.  Well, chemotherapy is an *option* but…it is most likely going to end poorly.  So, you’d like to know if you have recurrence, right?  I mean, it’s very important to know if you do or don’t?  Traditionally, CT scans have been the mainstay of this surveillance, however a new finding on CT may be a benign one and as such a second CT down the road may be required to see if this small lesion is going to grow or not.  Or maybe a biopsy. 

Enter the PET/CT.  This nifty technology utilizes a radiographic agent that is biochemically attached to, usually, a glucose molecule.  Cancer cells are highly metabolic and so they eat up the glucose AND the radiotracer and, voila, hot spots appear where there may be cancer.  In some cancers, this is practically the standard of care now.

So, why am I not impressed?  Well, first off, what do you know now that you have a positive PET?  Yeah, you know that you are indeed fucked.  Not a little, but completely.  Sure, a negative PET is a great thing and makes you feel hunky dory inside.  Really nice and safe and happy in the new little Honda you bought.  Wait, the what?  That’s right, inside the car that you purchased for this scan that told you that you either will or will not die from cancer.  Because a PET/CT costs about $15,000.  Most of that money goes to the very expensive process of creating the custom agent that is infused into your body.  It must be created at a cyclotron within about 24 hours of the procedure and as such, many such expensive facilities are needed in order to supply the many PET scanners with the product. 

 

Is the one on the right really worth 15 times what the one on the left is? I don’t think so.

And now…you have to have one every 3 months for the rest of your life.  Do you really think that your peace of mind is worth $60,000 a year?  I mean, that’s not a Honda, that’s buying a fucking Yukon Denali every year just to feel warm and happy.  Balding, fat, middle-aged doctors get to do that shit, not you.  But, who cares, you’re not the one paying.  I mean, a plain CT costs less than $1,000 now and can give you practically equivalent peace of mind, but…since the government or the evil insurance company is paying, fuck ‘em, let them pay.

It’s thinking like this that has gotten us into the worst imaginable financial position in the field of medicine.  So tell your fat, stupid doctor to shove his PET scan up his fat ass and just get a regular CT.  Make him show you the data on why it’s such a great idea for YOU in this case to get a PET scan.  Otherwise, fuck your doctor and the rolls of cash that he wants to put in his pocket.

 

 

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.