Money for Nothing, Healthcare for Free

Jumping the Shark

“My arm was numb after I slept on it funny and my mom says I’m having a stroke,” says my essentially healthy 34-year-old patient to the nodding approval of his indulgent mother sitting by the bed.

“How long did the numbness last?”

“A couple of minutes…it went away after I straightened my arm.”

“So your arm went to sleep and now it’s better?” I ask.

“I guess so.”

“You know that just walking through that door costs you four hundred bucks?”

“It’s okay,” interjects his mother,”He’s on disability and don’t have to pay a dime.”

And there, in a nutshell, is the problem with American medicine and why the looming government solutions are insane.  Don’t you all realize that when a healthy young man can walk into an Emergency Department because his arm fell asleep and be seen by a doctor, a doctor who will dutifully diagnose him with transient paresthesias or compression neuropathy or God forbid initiate an expensive and highly unnecessary work up; when a patient can present with nothing and less than nothing and run through your money with as much concern as I have for swatting a fly…don’t you all realize that when this kind of patient can leave without being arrested for fraud that American medicine has jumped the shark and making it even more accessible at even less cost to a growing population of supremely entitled citizens will result in nothing but an exponential increase in the baseline ridiculousness of it all?

Pill Pusher

The Emergency Department is the center of a thriving drug trade that would make an Afghan Opium Warlord gulp in amazement.  A truly staggering amount of narcotics leaves here every day and I am sorry to say that, even though I am trying to prescribe less of them, I have had a major part in this.  It’s not that I don’t believe in appropriately treating pain.  Cancer?  Major trauma?  Kidney stones?  No problem.  But every person with back pain, even if they were legitimate patients and not the drug seekers that many of them are, does not need thirty Lortabs…if they’re not allergic to Lortab that is as most of our narcotic connoisseurs eschew the slow onset of pills for the instant rush of Dilaudid (doctor prescribed heroin).

The problem is two-fold:  First, there are some patients who are in pain and have a legitimate need for narcotics.  You can’t withhold them because other people abuse the system and consequently it is necessary to give people the benefit of the doubt even if you know you’re being scammed most of the time.  Second, there is tremendous pressure bureaucratically to make the customers (formally known as patients) happy lest Press-Gainey scores suffer and some imaginary harm come the bottom line as customers who probably don’t pay for their medical care anyway threaten to take their business to some other, more accommodating drug entrepot.

So I’m sending a lot of people out on Motrin and occasionally Valium as a muscle relaxer and reaping the whirlwind of bad feelings and complaints.  If you’re in a minor automobile accident and walk in a day later without any injuries this is completely appropriate and why a little fender-bender in which no one was hurt and EMS were not called should be the prelude to a narcotic holiday is not clear.

That many patients lie to get drugs in an incontrovertible fact. I work at two Emergency Departments in town and I have had the same patient on two different days with two different descriptions of the same wreck.   I also occasionally get calls two weeks after the prescription for Lortab was written  for a minor motor vehicle accident claiming that the pharmacy lost it and could I please write them another prescription?

I have discovered from several of my more straightforward ex-drug seeking patients who now come in occasionally for minor but legitimate complaints (and refuse anything but tylenol or Motrin) that at one time they were selling their Lortab on the street for ten bucks a pill.  Apparently you can make a decent living scamming your Emergency Physician or, as the Pharmacist put it, “Hey Doc, did you know that Mr. Smith just filled a prescription for 150 Percocet two days ago?”

No.  No I did not.

It would be unfair to characterize the country as a whole from the self-selected few who have formed a symbiotic relationship with the Emergency Department.  But just like every medical problem is not an Emergency, every little pain does not need treatment and there was a time, I assure you, when people just took a couple of aspirin and called their doctor in the morning.

Jumping the Shark II

“You know I’m not a pediatrician,” I say to the mother of a well-looking, very healthy baby brought to the Emergency Department for a little spitting up and an inability to obtain an instant appointment with the child’s pediatrician.

Incredulous look.  Thinks I am some kind of on-call pediatrician.

“You know I’m not a dermatologist,” I say to a otherwise well man with a faint rash on his neck that started a few months ago.

Disbelief.  Anger at my referral to a dermatologist (who I called after coming up with nothing in my dermatology atlas) who will see him in three weeks but unfortunately will probably ask for money up front.

“I want to see the dermatologist now!  That’s why I came in.”

Good luck.  Heard muttering on his way out that he wanted his co-pay back because “that fucking doctor didn’t do shit for me.”

“You know I’m not your primary care doctor,” I say to the well-appearing woman with a complaint of “I want to be checked for sarcoidosis.”

Scornful look.  “Oh, my doctor isn’t doing anything for me,” although I suspect from a cursory review of her online medical records he is as he has at least ordered all of the appropriate lab work.

Somewhere, sometime…I don’t know when…the public has dropped even the pretense that the Emergency Department is anything other than an all-hours urgent care or some kind of one-stop shopping for all of your real and imagined medical problems.  It it this impatience, the medicalization of all aspects of life, represented by patients demanding instant treatment for things that thirty years ago would be shrugged off that ensures our health care system will bankrupt us, especially when it is free.

24 thoughts on “Money for Nothing, Healthcare for Free

  1. This is so well written, I want to copy/paste it to every media outlet I can think of.

    That sound you hear is me applauding.

  2. I find it almost unbelievable people come in with these complaints, but then again, that’s what happens when the bill is on everyone else’s dime.

    And by the way, thanks for writing again. You don’t do it enough! Come on here more often!

  3. Amen!

    I got into a Press-Gainey mess when the first thing I asked the patient was “what was their Emergency?” It is amazing how much time drug seekers will spend filling out satisfaction surveys!

  4. Dealing with the drug-seeking subculture is so emotionally draining. A constant cat and mouse game of “how do I not piss you off and still not give you your narcs.” One of my favorite methods is to say with as much feigned compassion as I can muster, “I would love to give you a script for your Percocet, but it’s obvious that traditional medicine has failed you. You’ve been here 13 times this year and been given Percocet and Lortab every time, so it’s obviously not the solution for you. I recommend alternative medicine, like chiropractic or acupuncture. I just wish I could help more.”

  5. Well said…What I want to know is that if this is the so called ‘information age’, how people can be so clueless?

  6. TheNewGuy says:

    Outstanding… as I was thinking it, Panda was writing it.

    Well played.

  7. And yet, here in the land of evil socialized medicine…we have no “Press-Gainey scores.” If a patient sees me and ends up unhappy, he can complain (we’ve got someone who fields complaints), the medical director (an MD, who works with me and also tries to make people happy but not at the expense of their health) looks over the complaint and he and I will talk it over and see if enything could have been done differently. Usually there isn’t much and he agrees he’d have done the same thing I did, and he gets paid to write a letter to the patient saying he’s looked into it and is satisfied with the care given.
    That makes….sense, doesn’t it?

  8. Great site, my friend. Totally connected with all your presented cases. Sometimes us ER folks represent the best and worst of what medicine has to offer.

    Just started my own blog…check it out if you get the chance.

    I will be following.

  9. Brilliant blog. I’m copying others and posting it on my facebook.

  10. Oh, you should submit these to a newspaper with national circulation.

  11. I always wonder, who was the genius who thought up patient satisfaction, or press-gainey, surveys? And who are the retards who continue to endorse them? What’s your department’s average response rate? I’m betting it’s on the order of 4%.

  12. Welcome back, Panda Bear. :-)

  13. Panda panda panda, you are awesome!

  14. Panda,
    Have been reading awhile. First time I have posted. Panda, you echo and reinforce what humorist P.J. O’Rouke said best…”If you think healthcare is expensive now, wait til it is FREE!”

    I spent all day in triage on Wed. educating patients on the appropriate utilization of the healthcare system. The ED is not your PCP, no we don’t refill chronic, routine medications month after month, you keep coming back here for the same complaint..have you followed up with say Ortho, PCP, OB/GYN, Pain Managemant (whomever)as instructed? No, they never follow up or call to make appt with specialists as instructed and “because I don’t have insurance” is the #1 response.

    Great, I say, all the money you have saved on insurance premiums should allow you enough money to pay for the MD visit which would be MUCH cheaper than repeated ED visits (which THEY know and I know they are not paying, either!)

    Next is- “I don’t have any money” from the pack a day smoker, 12 pack a day drinker riding around in a $40,000 truck.

    Have you been to the Commmunity Care Clinic (free)- No, I didn’t know there was one.Give referral- still don’t go.

    Have you called the specialist office and told them your situation and asked to be put on a payment plan- the answer is always , NO!

    Bottom line, when did “I don’t have insurance” become THE accepted, universal excuse for personal irresponsiblity to not take care of you own health care needs?? They think those with insurance don’t pay anything- we still have the costly premium,deductibles, copays and 20% insurance doesn’t pay. We call and get set up on payment plans for large medical bills incurred AFTER insurance pays–that’s what I do and they are always accomodating!

    This idea has never crossed the mind of the 44 million Americans that don’t have insurance.Of which, 30 million CAN afford and CHOOSE not to PAY. Not that they can’t afford- they don’t want to PAY and since it’s not mandatory like car or homeowners insurance they don’t do it! Look, buddy- I don’t LIKE paying for it,either- but I do! The other 14 million truly cannot afford it and for them I have some compassion.

    Yes, these are hard ecomomic times and many folks have lost insurance and are out of work but I was hearing these same comments during the boom time. Having no money is all the more reason to go to MD at $60.00- 100.00 than an ED at $400.00 for just walking through the door before anything is even done!

    Needless to say, we still saw all the repeat offenders on Wed.- we have to- it’s the law (none of which were emergencies).However, I “paved the way” for the ED doc which, of course, was communicated so that the patient was not surprised when MD did not meet their needs or “make them completely satisfied” as our Patient Satisfaction Police insist upon. Prepared the patient for what was coming and made sure the doc was on the same page so there was no mixed messages.

    Let them go visit another ER tomorrow- that they are not going to pay, either and see if that one can make them completely satisfied. I was tired of Loserville Repetitus and spent my day on education (part of my nursing responsibility, right??!!- It’s in my job description.) I’m sure I did not help our patient satisfaction scores one iota!

    These folks want the Nanny State not wanting to pay one dime for their own healthcare needs except for thier narcotic refills!They don’t want to be inconvenienced by “making and appt” for routine problems and waiting for appt when they can walk into any ED and be seen “free” on their own convenient time.

    Love the site- saying what all of us are thinking and deal with everyday!

    Thanks, Panda

    911RN

  15. My heart aches to see a SDN thread under topics in healthcare where the purveyors of acupuncture feel not only superior in their treatments, but also call those who refuse it arrogant and ignorant.

  16. Panda doc,

    Came accross you blog this evening whilst researching entry into medicine at a later age than normal. Background somewhat similar to yours and I’d much appreciate the chance to throw a few questions at you if I may. I’ll return to that.

    I’m in the UK so much of what you comment upon regarding funding / cost of treatment for patients is different here, but I would make one observation to slightly mitigate those who needlessly “clog up” ER (A&E in the UK). We live in an increasing culture of emergency, panic, blame and responsibility; and are bombarded by media telling us how any little pain could in fact be a life-threatening illness. Whilst this may well be preventative and educating, I believe that it also creates needless worry and anxiety, and hence it would behoove us not to berate (some) presenting patients as timewasters, as they may well be simply following advice they have watched or read.

    How one judges the difference between such people, and those who are genuine malingerers is however a far more taxing questions, and not one which I feel qualified to answer.

    To return to the reason I stumbled upon your blog – I am seriously considering a late start to medicine and would much appreciate the opportunity to ask you a few questions.

    Regards

    Richard

  17. Panda
    What are your feelings about the negative impact of nursing unions in Emergency Medicine.
    It appears in my shop not a day goes by where more efficient patient care would result from the loss of our inneficient union rules and union nurses. Incentivises the nurses like physicians to get them of their keister and up in action.

    I also had the recent privelage to find information indicating higher patient satisfaction scores and decreased length of stay in hospitals without unions.

    If doctors can not have unions because it affects patient care, why can nurses??

    I grew up in an area where the primary work force was blue collar people and every union based company eventually failed due to the inability of companies to survive while navigating around these union rules (they call them union laws but I haven’t seen any congressional vote)

    What are your thoughts?

    Dr M

  18. A quick note to all PB readers: I *highly* recommend storytellerdoc’s blog (linked above).

    http://storytellerdoc.blogspot.com/

    PB, not sure if you actively monitor comments, but if so, may I recommend putting this entry in your blog-roll? It’s certainly qualified as a permanent entry on my favorites list.

  19. Pingback: Links! « fi-ology
  20. Do you not have triage nurses in the States? That first guy you talked about literally would not have been able get inside an ER around here, let alone see a doctor…

  21. Did it ever occur to you that, in fact, it is the medical profession itself that has succeeded so well in medicalizing every aspect of our lives? You have pushed so much the image of GOD, the doctor, that it has all come back to bite you in your own butt. You clearly want to lay blame on all the “commoners” you obviously regard as twits and morons and idiots, but it was your own hand that has fed them the cake of entitlement. You’ve participated well in creating a bunch of dependents, so stop your whining and try some education, rather than condescension.

  22. LAWYERS, not physicians, fed the twits the cake of “entitlement”. LAWYERS have created ” this bunch of dependents.”. Torte reform now! Let the physician practice medicine rather than practicing coving his ass. LOL

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