Overdoctored

Rocking Your Fragile World-View

Let us again consider Albania, a tiny country tucked into a little corner of Europe which is only now emerging out of the communist Dark Ages in which it had stagnated while the rest of Europe moved on. This very poor country sits on the Northern border of Greece for whom it serves as a sort of Balkan Mexico, sending a steady stream of poor illegal immigrants into Greece looking for a better life and overwhelming the Greek welfare state. The average life expectancy (a statistic that sleek United Nations bureaucrats and the People Who Love Them use as a surrogate indicator for the quality of a nation’s health care system) of an Albanian is close to 78 years. A typical Frenchman, since France is held to be some sort of medical Shangri La by many Americans, can expect to enjoy pointless cinema, runny cheese, and l’ennui francaise for around 79 years. The typical American might live a few months less than a Frenchman or other comparable European but he can reasonably expect to live as long as an Albanian as will the typical Greek. The United States spends the most per capita on medical care followed by the French, the Greeks, and lagging way, way behind, the hardy Albanians who, despite spending less per capita on medical care than many Americans spend on frothy coffee drinks, still manage to hang on for a long life that is only a matter of months shorter than that enjoyed by a Frenchman, a Greek, an American, or just about anybody in the the rest of the developed world.

Indeed, those thrifty Albanians manage to spend less than 400 bucks apiece per year on medical care, have almost none of the advanced treatments available in the United States or the European Union, very sketchy access to doctors, and still manage to live long, healthy lives eating their Tavi Kosi and smoking their harsh Red Star Tractor Brand unfiltered cigarettes. By comparrisson, we spend close to 6000 bucks per head per year, the Greeks spend about 2500, and the effete French spend around four thousand. If you look at the rest of the developed world, there appears to be a similar discordance between health care exenditure and longevity. Past around six hundred bucks, typical of most of the Balkans and other emerging European nations that have reasonable sewage and other public health measures, there doesn’t seem to be much of correlation between spending and longevity. Maybe a two or three year difference between the top and the bottom which shouldn’t be anything to get excited about. I can easily think of a couple of cultural factors that might account for a bit of this slight difference. In the United States, for example, every Tupac harvested early to the Lord in a pointless rap war, besides being a mighty blow to the music world, drives down the average life expectancy.

I have also never seen, in all of my extensive travels in Europe, anything remotely similar to the four or five-hundred pound behemouths that roam the American landscape in vast herds, making the buffet lines tremble from the thunder of their comfortable shoes and darkening the parking lots of all-you-can eat waffle joints across the fruited plains. I mean, I’m treating obese kids with with type II diabetes, most of whom have free health insurance via medicaid and of which their parents avail themselves with the same gusto they otherwise reserve for nacho cheese biscuits. Lack of health care is not the problem here, nor is access.

In earlier articles I have suggested that we waste a lot of money in the medical industry. How much, exactly, I am unsure. There is a large gray area between what I would consider the completely appropriate use of medical resources and what I know to be the equivalent of flushing burning hundred-dollar bills down the toilet. But I think that most of my learned colleagues on the medical internet will agree that wasted money accounts for a horrifically large percentage of our total two-trillion-dollar yearly spending binge.

Oh my loyal and long-suffering readers, you who I delight in entertaining with detailed prose as I attempt to wrap the truth of the world, or at least how I see it, in a little bit of humor, a little bit of sarcasm, and a little bit of shameless pandering to the understandable instinct to despise the French; I confess from the depths of my black, misanthropic heart that I am not much of a writer. I try hard, of course, and I can occasionly tame an idea or two in my brain long enough to lead it to paper but since I am having a hard time thinking of a clever way to illustrate exactly how much money we waste in this country on medical care, I’m just going to say it plainly with no art or interesting literary devices. Just Keep in mind two things. First, I’m going to tie it all in to the Albanians and second, every patient I’m going to describe costs the system money even if they are what is optimistically called self-pay (a cheerful euphemsism for “There is No Way in Hell I Would Pay a Dime for my Medical Care”). The temptation is to say, “Well, since they can’t pay there is no money changing hands and therefore no real cost to the health care system.” This, however, is a stunning example of wrong-headed thinking. Every patient costs money to somebody if only because the infrastructure to deal with them has to be maintained. Of all the individuals and organizations involved in delivering medical care, the only ones who will work for nothing are doctors. Try getting a nurse or a radiology tech, for example, to work a few extra hours or fill in some holes in the hospital’s schedule for free. They’d laugh, as would the janitors, clerks, and even the nice ladies slinging the chili mac down in the cafeteria. Medical care is a huge team effort involving expensive infrastructure and many highly skilled and not-so-skilled people, none of whom would even consider volunteering their time except, as I mentioned, physicians who are not only regularly asked but expected to work for nothing as the need arises (a typical Emergency Physician working on a production basis and not as hospital employee, for example, gives away a hundred thousand bucks of his time every year).

So let me just state that In the United States, we are terrifically over-doctored. Much of what we spend is to overtreat either self-limiting things or to throw marginally effective therapy, at least in regard to decreased mortality, at chronic medical problems, most of which are lifestyle related. Either that or we burn through money like drunken sailors on futile end-of-life care for people who have absolutely no quality of life unless we are now measuring quality by how long you can lay motionless in your own urine before a minimum-wage nursing home caregiver decides to roll you around a little. Let me give you a few examples of typical patients to illustrate the many ways in which your money is squandered.

“There, you see? She blinked! I love you Grandma!”

I see this patient or some variation at least once on most shifts. An incredibly frail, some might say cadaverous, woman, somewhere in the neighborhood of ninety who has been in a nursing home for a decade and was doing all right with her end-stage renal disease, advanced senile dementia, and congestive heart failure until about a year ago when something broke loose during dialysis and she suffered a stroke, turning her from a demented elderly lady who had broken her hip twice to a demented, aphasic, ancient lady; completely immobile except when indifferently turned by the staff of the warehouse in which she is stored. Because she can no longer swallow the surgeons obliged her family with a PEG tube (to pour liquid food directly into her stomach) and to protect her airway she breathes humidified oxygen through a tracheostomy (a hole in her neck, with another tube sticking out of it). On a philosophical level we can debate the nature of quality of life but I’m going to go out on a limb here and suggest that laying in your own feces on eroded bed sores is not much of a quality of life. In other words, we’re not talking about a hale and hearty nonagenarian who will live to be a hundred provided she can avoid being admitted to the hospital. This is a patient who is living on borrowed time, one who will not last another six months despite our best efforts and yet, in those last six months we will spend large sums of money on her, probably more than the total spent in her whole pre-stroke life, in an inexplicable quest to stave off death, spending money at an increasing rate the closer she gets to actual “reaper” death and not the living death to which she is condemned.

It is also both amusing and edifying to peruse a list of her medications which, after a decade or two of failing health, has grown into a two-page manifesto, a declaration or our faith in evidence-based chemistry. For starters she is on three-hundred dollars a month of Namenda, a new drug that is only marginally effective in improving the memory of patients with early Alzheimer’s but, if you think about it, is kind of ridiculous to use in a patient who is so far gone that even before her stroke she couldn’t even remember how to feed herself. Because of her cardiac history, she is on the obligatory statin and beta-blocker although against what looming cardiac event we are protecting her is not clear. Because of her atrial fibrillation, for which she recieved an implanted defibrillator two years ago, she is on coumadin. Now that she has no risk of ever getting up to fall it has been cranked up, giving her the occasional gastrointestinal bleed as her doctor disinterestedly tries to control her wildy fluctuating levels. As a little bit of seasoning she is on the digoxin to keep her heart beating as well as the usual four or five narcotics which are poured carefully into her feeding tube at regular intervals with the rest of her medications.

We pour expensive medical care into her in equal measure. The PEG and tracheostomy are only the latest procedures. If the squad of specialsts following her play their cards right, she’s good for at least a few bronchoscopies, an echocardioram, and maybe even a battery change on her defibrillator before they’re through

And she’s a full code. The family wants “everything done,” no matter what, up to and including artificial ventilation, defibrillation, and even more tubes. You see, “She knows we’re in the room, doc. Can’t you see how she perks up when we speak?” Against this kind of faith there is no argument possible, not in our totally out-of-control health care system where, since somebody else is always paying, money is no object. I have no doubt that the last six months of her life is going to cost a couple of hundred thousand dollars. A day in the intensive care unit by itself costs a cool four grand. She will probably burn through a couple of weeks of these before the final, terminal admission where at last, somebody has the common sense to say “no mas” and, after one final orgy of spending (for old time’s sake), we finally let her go.

Where’s the Fire?

Every now and then our already busy Emergency Department is innundated with a surge of patients. The waiting room is packed and the over-flow are seated in folding chairs in the hallway. The chart rack spills over, five rows deep instead of the usual two and you’d think a plane had crashed or the Four Horsemen were abroad. A quick survey of the new charts, however, shows the usual minor complaints, things that eventually turn out to be colds or vague abdominal pain. The panic begins, tempers get short, and, already working at a dangeorus speed, we are expected to double our efforts and move patients. God forbid we get a critical patient at a time like this because that will gum up the waiting room to an unacceptable degree. Why, and please try to choke down your horror, people with minor complaints might even get tired of waiting and leave the department without being seen. Which is sort of the problem. While it is no doubt true that hidden among the irritated patients spilling into the hallway is a real, honest-to-God heart attack or a smouldering acute appendicitis about to become dangerous, the majority of the deluge are patients with complaints that turn out to be minor, self-limiting things or even no problem at all except the siren call of the only representative of the all-giving and all-powerful Man that is open at 2 AM.

Now, I’m not saying that patients don’t need to be seen. Many have no other access to medical care and some are really quite sick. Although I would hate for the Emergency Department to become a primary care clinic for the indigent (a direction towards which we are lurching as hospital bureaucrats think up even more ways to jack up Press-Ganey scores), there is a need for medical care that somebody has to fill. On the other hand many of the complaints are so minor that they don’t need to be seen at all, even if the patient has premium insurance and is followed by the best internist in town. A request for a pregancy test, for example, should never make it past triage. Likewise what is obviously a cold in an otherwise healthy young adult. It is true that both of these complaints might be more than they seem, the pregancy may be an ectopic and the cold may be a Wegener’s friggin’ Granulomatosis but that doesn’t mean that they need to be worked up, a difficult concept for people to understand.

Or, to put it another way, if we work up every minor complaint under the sun looking for a big, bad, macho, internal-medicine-type thrill kill we won’t miss it when it pops up but we are going to have a horrifically expensive health care system with money being spent where it will do the least good. I’m not implying that every cold gets the million dollar workup. We still have a little common sense left. But these patients are dutifully triaged and seen, leading to crowding in the department, already more than a little constipated with “Emergency Department Admissions” (patients with orders for admission but no available beds or nurses in the hospital). There is no “Triage to Home” which is what we really need (and not just in the Emergency Department but in the whole medical profession), that is, a designation for a patient who has been quickly assessed by a skilled nurse, a PA, or even the Emergency Physician making waiting room rounds to not be sick enough for a full work-up and diagnosis. Because somebody pays, you know. Every chronic back pain, every cold, every vague psychosomatic disorder costs money somewhere. The tab is either picked up by Medicaid (and Medicaid patients are ravenous consumers of free healthcare), Medicare, private insurance, or even on rare blue moons when lightning strikes, by the patient himself…but it is all part of the two-trillion dollars we spend every year. Even if the care is unreimbursed the cost to maintain the needed capacity is very real and paid for by everybody.

The idea that some socialized, quasi-socailized, it-ain’t-socialized-much-cause-it’s-single-payer, or any other scheme to give everyone free medical care is going to alleviate the problem is laughable. While there is currently some restraint in the system against using medical resources for minor complaints, it really only effects those who make co-pays for their medical care. If you pay nothing, there is no incentive not to crowd the doctor’s office or the Emergency Department for your free pregnancy test or your motrin. All you have to spend is your time and while our department sometimes slows to a crawl with ten hours waits, you can usually be seen in three or four hours. A long time but I have waited an hour or two to see my doctor for my annual physical (itself largely a waste of money for an otherwise healthy guy) when he is running behind. What’s another couple of hours if it’s free?

What We Have Here is a Failure to Communicate

How many cardiac workups does one person need in a year? Or how many CT scans? Because I work in the Emergency Departments of two rival hospitals I am in the unique position of getting a patient admitted for vaguely cardiac-sounding chest pain and then, as if nothing happened, seeing him at the other department often only a few days later with the same complaint and, unless he remembers me which he may not, no mention in his past medical history of his completely negative nuclear stress test and exhaustive workup. The story is the same for all manner of patients. Some, like drug seekers, attempt to game the system and make the circuit of local Emergency Rooms, shamelessly spinning a tale of woe four or five times a week. Others just don’t know any better and, despite having various deadly conditions definitively ruled-out on multiple occasions at other hospitals, are perpetually looking for the definitve second opinion, or attention, or someone to take care of them for a few days…who knows. Some people just feel bad all the time and have developed a co-dependent relationship with the hospital. They suck down many, many scarce medical dollars in redundant tests, consultations, and brief hospital stays where, in reading the discharge summary, you can sense the dictating physician trying to express his frustration without out-and-out accusing the patient of malingering. For our part, they are what we call “weak admissions,” embarrassingly weak, the kind that make you cringe to discuss with the admitting service.

Some patients, let’s say someone with a volvulous, are incredibly strong admissions. All you have to say is, “The patient definitely has a surgical abdomen, is distended, tender, guarding, and vomitting,” and the admitting surgeon will say, “Okay, I’ll be right in.” Some admissions are decent, like a 65-year-old smoker with pneumonia. You will rarely get an argument or the telephone equivalent of rolled eyes. Some admissions are weak but so routine that the admitting service will demur with little complaint. Some are so weak, so worthless, and such a waste of money that I cringe to hear the voice on the other end of the line, rippling with sarcasm, saying, “You know we admitted him for that last week and found nothing, don’t you?”

Or worse yet, “Oh, we had to discharge him from our practice for violating his pain contract and trying to get narcotics from almost every hospital in the state.”

And you’re left holding the bag, playing a game of legal chicken. The patients may cry wolf but there is going to be a real wolf someday and, like a game of hot potato, nobody wants to be holding the spud when the music stops. I have a patient like this, a serial abuser of Emergency Services whose hospital tab must run in the millions, who came in one day in her usual excruciating pain but which this time was not relieved by her customary dose of narcotics and who turned out to have a perforated colon.

There are two salient points here. The first is that the medical profession does a poor job of coordinating information. It almost makes one wish for a standard, nation-wide electronic medical record accessible by every physician and made mandatory for everyone. In this manner, every prescription, test, study, and discharge summary could be pulled up and viewed by any doctor. The second point is that what we need isn’t a Good Samaritan clause (protecting physicians who offer free care) but a “Wolf Clause” to set an upper limit on the amount of work-ups and Emergency Department visits allowed for one patient. I have a 22-year-old patient, an otherwise healthy young woman, who has been to our department thirty times in the last year, been hospitalized a few times, been worked-up redundantly at both of our big hospitals, and there is nothing physically wrong with her. But she is a spud, and since I’d rather spend your money than risk my livelyhood, we take her seriously every time we see her. We may joke about it and roll our eyes but we don’t dare put our money where our mouths are.

What’s Albania Got to Do With It?

Nothing, really. Except that the Albanians don’t have anywhere near the access to high-tech health care that our citizens enjoy. Like the Greeks and many other Europeans, even their sickest patients are not typically on a long list of medications. There is nothing like our buzzing Emergency Medical hives in Albania where every Albanian who is not feeling well can get relatively instant access to almost every labratory test, imaging study, and specialist known to the medical profession. In Albania, much of what we consider the standard of care is unheard of and reserved for those who can pay for it up front. You certainly will not have your terminal illness interupted by too many of the heroic measures which are routine in our country, even for the poor. People grow old, get sick, and die almost as they have been doing since my ancestors regularly invaded and enslaved theirs.

Ah, Albania! Tarnished Jewel of the Balkans! Despite no medical care to speak of you live as long as we do and even give the perfidious French a run for their money. What does that say about how we spend money? I am pefectly willing to concede that there are quality of life issues at play. Certainly I’m glad that I may one day get an artificial knee if mine should ever wear out. And I also concede willingly that if I were critically ill, I’d be immensely glad to be in Pocatello, Idaho and not Tirana. But I’d like to humbly put forth the notion that most of the money spent on medical care in the United States and Europe is spent on the margins, which is not to say that people don’t want it and don’t demand it, but only that it is spent in large amounts with very little to show for it. Maybe past a couple of thousand a year we’re just pissing in the wind. And maybe what we need to do is to start doing less for most patients, most of time, reserving our big guns for worthy targets and not for killing gnats.

26 thoughts on “Overdoctored

  1. I don’t always agree with you. I’m a bit more socially liberal than you are, but I totally agree with you here. I think the most frustrating thing about these issues is that the vast majority of them have relatively simple solutions. Let’s say we charged a $10-$50 copay for all Medicaid/Medicare ED visits (I have private insurance and my copay is $50). That might be a suitable disincentive to stay away from the ED.

    Also, one way of getting people to take care of indigent patients is to offer student loan forgiveness. Lets say that the government would forgive all of my student loans if I would work for them for… say 5 years at a salary of say… $70k. I certainly would give that offer serious consideration.

    Additionally, as a society, we need to make some decisions about what we’re going to pay for. Private insurers and the US government should draw up some guidelines about the care of the 90 year old completely demented etc. patient you describe above. Sure, if granny were running around having a great time, and then had pneumonia with ARDS, I’d be willing to pay for a trial of ICU care. But the case you describe (which I saw plenty of on my medicine rotation), it’s ridiculous to keep paying to keep her alive in a miserable quality of life which will never get better. Who in their right minds would want that?

    Also, we have refused to admit some of the weak admits you describe to the gyn service. 20 year old non-pregnant woman with pelvic pain and no evidence for a gyn etiology,admit for pain control? We often say, “no. she has no evidence for a gyn problem, we’re not admitting her”, knowing that it puts you ED people in a bad position, and that she’ll ultimately likely get admitted to internal medicine. I think that some of this is due to the patients expectation to never have pain.

  2. grumpy old scalpel says:

    Panda, you are a great writer. I am in the middle of clinic, waiting for the next patient to come in, and I just laughed out loud reading this. You have got to publish a book, I’d buy it.

  3. Dave G Pharm D says:

    Panda, great post!
    Al-bay-nee-yah, Al-bay-nee-yah, you border on the Ay-dree-ah-tic!! (Couldn’t resist a little, albeit, antiquated humor from Cheers)

  4. I would love nothing more than to see a national electronic database. It would make care soooo much easier for everyone involved. I’m sure that privacy rights advocates would balk at it, but given the abuse of the system, the patients’ ignorance of their previous history and medications, and the duplication of efforts by many physicians, the single best way to reduce the cost of healthcare in the long run would be with a national database. As we head ever more toward socialism, I at least hope that docs can get some benefit out of reduced salaries. Unfortunately, I’m afraid that we’re going to keep playing hot potato with lighter pockets and more paperwork.

  5. Here’s an article that shows the adjusted life expectancies of a few countries when accidents and homicides are eliminated…

    In short, we have the longest life expectancy when these are removed despite being morbidly obese, even at very young ages.

     

    (Well, yeah. I know this and I am being somewhat facetious comparing Albania to the rest of the developed world.  But you see that, like I said, there appears to be no correlation between spending and longevity which probably indicates more that lifespan is a poor surrogate for the quality of medical care than it does anything else.  But if we’re going to throw life-span around as the A-bomb, the argument stopper, the sine qua non of quality, than the French and the Greeks have got a lot of explaining to do because, while they may not spend as much as we do, they are spending an awful lot with very little to show for it.  At least in the United States you can get dialysis if you need it which is not the case in the rest of Europe past a certain age and condition.

    But still, we waste money at an alarming rate.  I know this from the bottom of my heart and it will take a societal seismic event, what exactly I don’t know, to change this. -PB)

  6. Ed Sodaro MD says:

    I drove to and toured Andorra 2 years ago, an obscure Pyrenees Mountain ministate. Andorra has the highest human life expectancy on Earth, on average of 83.52 years according to the US Census Bureau (2007 est).

    It is ethnically heterogeneous (the Andorrans are a minority in their own country), so the lame typical US excuse doesn’t fly. They smoke tobacco (which they also grow as a cash crop), but in declining amounts. The health care system is unremarkable but competent. The winters are long and hard up in the Pyrenees.

    Longevity etiology? I dunno, but they are all skinny, they walk everywhere in their mountainous homeland, the food is freshly prepared and delicious, there is no Type II crappy American diet poisoning (oops, I meant diabetes), and they laugh a lot.

    Ed Sodaro MD

  7. I’d guess that if more Albanians could afford dental care they’d live even longer.

    My sister went to Eastern Europe on a mission activity and teeth seemed to be the biggest issue most had. Of course the solution is simple, out they come.

  8. I am for the electronic medical record provided 1. the public consents to participating, every last one of them, no exceptions and 2. they also pay for it, all of it, all the hardware, all the software, all the training, all the support and upgrades and all the security.

  9. anonymous says:

    After seeing my dad die in Arizona while not being able to get a little beyond specialized medical care– he was a very healthy 68 year old man who was in better shape than most athletic 30 year olds and the medical people kept telling my mother that he was elderly and wasn’t going to live for forever– I have no idea how you are intubating elderly people who have long since died but are still breathing.

    I hate seeing doctors and I just got yelled at (really, I was yelled at, but the doctor and I like each other) for not telling my doctor something about bleeding between cycles until he noticed some other problems that I wasn’t aware of and he asked. What one doctor and nurse nurse roll their eyes at and say I am getting older and to not worry and are sick of hearing me talk about, another doctor sees as a sign of major problems. I’m getting my uterus removed in several weeks. I’m educated– shouldn’t I have known there was a problem? Based on my experience and hating to feel stupid, it wasn’t a big deal.

    You will always have people who want attention whether they need it or not and end up in ER’s and exaggerate their problems later to their friends, then you will have people who hate seeing your kind (doctors) who’d almost rather die than be touched– had I been with the other doctor another year, I’d have some major problems. Then there will be people like my dad who manage to slip through the cracks for getting care and become a liability in spite of clearly displaying problems that could easily be diagnosed. Educating the patients only works so much. Patients telling their doctors what they need to know may or may not work.

    Do you really think that anything can change? We can work the system a bit one way and then another but the problems will still be there because of who the patients are. Medicine is practiced a certain way. Patients are all over the place in terms of needs and believability. You may change the game, but the players are still the same and I don’t think the outcomes will change.

    (Albania has it right, but you know, they also eat better. They don’t have fat mothers feeding fat kids strawberry marshmallows and pizza puffs for dinner.)

  10. Bryan Caplan has written about Singapore’s health care system, which you might find interesting. There’s also a link on that page to Robin Hanson’s Cato essay “Cut Medical Spending in Half.” Hanson blogs here.

  11. random lurker says:

    Okay, since you mentioned your writing skills, I need to say something. Your points would come across a lot better if you’d ditch the ridiculously florid and wordy writing style. You have some good points, and I totally agree with this entry by the way, but when the salient ideas are buried in a lot of convoluted sentences and flowery phrases, it lessens the impact.

     

    (Honestly, I don’t know how to respond.  If I eschewed any attempt at literary skill my entire blog would be about a page long.  Are you suggesting I just state my key point in one line or two and leave it at that without making any attempt to throw a little “art” into it?  As you may or may not know (because I’ve mentioned it) my literary models are Dickens, Melville, Graves, and Orwell, all fellows who were known for a convoluted sentence or two.  While I don’t have near the skill as these gentlemen did, that’s why writing requires constant practice.  It is a sad commentary on our age that you can’t appreciate a “wordy” writing style.  Not everything has to be delivered to you in a Happy Meal format. -PB)

  12. BlackSails says:

    random lurker- not everyone has to write like Hemmingway.

  13. Scutslave says:

    Re: Diagnosing someone with “malingering”.

    Did this once in the ED a couple months ago, after a guy who had been discharged four days previously came in with a bogus complaint that was worked up negative (after a long sequence of physical exams, tests and imaging). He even admitted that he was looking for “three hots and a cot”.

    The end result: My getting called in to speak to the division chief, who point blank told me, never to use that diagnosis as “I could never be sure.”

    The resistance to seeing things as they are, can be mind boggling.

  14. Wow.

    Spot on excellent piece.

    Of course you know, such common sense is not to be tollerated in the mainstream press or in Washington, D.C.

    No, by all means, we need more government intervention.

    We need more bureaucracy.

    We need more money spent on healthcare.

    Ugh!!!!

  15. PB – I think your writing is OK. As you say, practice makes perfect.

    You made your initial statement, you ambled your way through it, and then pulled back to the initial idea in the end.

    Blogs can have a more conversational tone, they aren’t newspapers. If you go read DB’s Medical Rants he has a different tone. He’s pretty terse. You aren’t. With you it’s a story and you’re telling it.

    I’ve often thought that DB should be writing the “Happy Hospitalist” and the HH should be writing “Medical Rants.” Their titles are misleading.

  16. I understand what you are saying about saving the “big guns” for those who can truly benefit from it and show some quality of life afterward. But, how will we maintain our skill at implementing these things if we aren’t constantly doing it?

  17. Don’t change your style Panda. It’s the journey that is the fun part of reading your blog entries.

  18. Charles Dickens was a bit “wordy” but all his writings are pure classics and always will be. I prefer the writings of David Pryce-Jones, myself. He marches! But I love this blog, Dr. PandaBear, and am so grateful you give time to it for us. I’ve never felt that a single word of it was unnecessary or uninstructive.

  19. Pancho Villa says:

    I agree with the people that enjoy your blog. If it wasn’t “wordy” it would just be an irrelevant amateur newsjournal. It’s a blog.

    I come here to read these “words,” so don’t change your style. Show of hands for who likes these “words?” Show of hands for nays?

    I thought so.

  20. Dr. Panda, I’m a bleeding heart liberal who has never and will never work in the medical field, but I enjoy reading your blog because of your extremely entertaining writing style (I had to call the espoused one in from the living room to share the above Tupac comment). If I want a dry analysis of medical and sociological issues, there are plenty of other websites available, and those who can’t appreciate a well-turned phrase are in the wrong place.

  21. TheProwler says:

    I love your writing style. By all means, continue to improve it, but don’t cut out all the amusing sayings – they’re at least half the reason why I come here and not the other blogs that simply post one cool article after the next rather than contributing original content.

    And this post is one more nail in the coffin of my potential emergency medicine career. I opted for EM as my M3 elective, but I’m thinking more and more that it will serve to rule it out rather than convince me that it’s the right one. I just think I’d punch that woman in the face for coming to my ER 30 times a year.

  22. chris swenson says:

    I follow alot of health blogs but respond to few. Emergency Rooms do get alot of weird things, but my own experience has been mostly good. I have been in my local ER many times with my kids as they were growing up — lacerations that needed stitches on a weekend (that’s a reasonable reason to go, right?) broken bones (we’ve been through 3 wrists, two fingers and one arm) — that’s a reasonable reason to go? Appendicitis (that was me) with surgery the next morning (the surgeon didn’t arrive until 7:00 AM so I had many interns learning about “rebound tenderness” until I punched one of them. A couple of pregnacies (that’s me).

    But I admit, sometimes ER’s are abused. My mother is now older than I (I guess she always has been) and is living in an assisted living kind of place. Whenever she falls (and old folks fall alot — but my mother just rolls with it — I’ve seen her fall when I brought her to a Broadway play and at my daughter’s musical recital, at my son’s soccer game). The assisted living place insists that she must go to the emergency room when she falls — this requires an ambulance and an examination etc. It seems excessive to me — is it really required to send an 80 year old woman to the ER every time she falls? Even if she says she does’nt hurt? Sure, she has osteoporosis and might break her hip, but wouldn’t that hurt? Couldn’t you ask her if she needs to go to an ER?

  23. Reminds me of this quote from medical sociologist Irving Zola:

    “… Sometimes it feels like this. There I am, standing by the shore of a swiftly flowing river, and I hear the cry of a drowning man. So I jump into the river, put my arms around him, pull him to the shore and apply artificial respiration. Just when he begins to breathe, there is another cry for help. So I jump into the river, reach him, pull him to shore, apply artificial respiration, and then just as he begins to breathe, another cry for help. You know, I am so busy jumping in, pulling them to shore, applying artificial respiration, that I have no time to see who in the hell is upstream pushing them in.”

  24. Panda! Your writing is exquisite! The best I have read on any blog, and I have read a fair share of them. Yours is definitely a thinking person’s blog, so keep in mind that those who want to be spoonfed will complain because they can’t understand all the vocabulary you’re using/ideas that are being put together/complex sentence structure. Remember, most of America is passed through high school English because their teachers couldn’t bear to have them through another year :). Their commentary should be ignored as one can’t properly critique something that one doesn’t understand. Seriously, your writing rocks, it’s apparent that you put thought and time into your posts, and I appreciate it every time I read. I love your blog (and not just because it’s nice to read someone that agrees with me :) ), but you really have a way with words, putting ideas together, and making it witty and humorous (as oftentimes the issues you’re discussing can be seen as dry, which is why they’re probably not discussed more thoroughly in the political arena other than by using simple inflammatory statements like “HEALTHCARE FOR ALL”). It’s really great to see thoughts and complaints that I’ve had fleshed out into properly functioning and well-written essays. I frequently pimp your blog out to those that I feel can appreciate its awesomeness .. Thank you.

  25. Don’t change a thing. Or word.

    My first visit here and it made me laugh out loud several times, not easy for a cynical old misery like me.

    The “sort of rationed” UK healthcare system does avoid some of the crazier excesses you describe, but according to my wife (the ex-internal medicine resident) the things you describe are all easily recognisable here too, especially the insatiable demand.

  26. Panda,
    I think you and I are soulmates, even if I am a drug rep.

    People use it because they have it, is my observation. Also, the end of life issue becomes so fraught emotionally that people become unhinged. My husband, who on other fiscal matters is quite sane and who agrees with you completely in theory, becomes outraged when I suggest that his demented, incontinent, aphasic mother does not need to take her Lipitor, Norvasc, Namenda and Razydyne. At the same time, he tells me over and over he is going to commit suicide if he ever gets diagnosed with AD.

    I can only pray that his mother dies a quick death, when she finally succumbs. I couldn’t keep my mouth shut in the face of an NG tube, etc.

    Horus

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