State of Fear

Struggling for Rationality

“This patient,” I said to myself, “is going home.” 

I know.  She’s 85 with the dreaded complaint of “Altered Mental Status” described by the family as a brief period of “staring.”  No generalized seizure activity, you understand, and no syncope (fainting), slurring of speech, facial droop, drooling, weakness, confusion, sweating, fever, nausea, vomiting, or any of the other symptoms or combination of symptoms upon whose fulcrum are levered mighty weights of flesh into the processing mill that is your local hospital.  In fact, this very pleasant lady felt fine and even the family admitted that she looked normal.

“And I’m not going to spend $20,000 proving she’s fine either,” I continued to myself as I screwed up the courage to throw out the rule book and guide my clinical judgement by history and physical exam.  After four years of medical school and four years of residency training I can do that can’t I?  Isn’t that what my professors, comfortably barricaded behind the litigation-proof walls of the State Charity Hospital told me I should be doing…especially as my history and physical exam confirmed the diagnosis that seemed obvious from reading the triage note and talking to the the paramedics on their way in? 

But then the fear gripped me.  That smouldering dull fire in the gut that can only be quenched by a deluge of unnecessary lab tests and studies. 

And I paused.

My computer glowed seductively.  It would have been easy to click here, click there, and then call the tired hospitalist to admit the patient.   We admit for this kind of thing all the time, slipping the patient in behind a smokescreen of irrelevant data; leveraging confusion, convenience, and sloppy medicine into countless unproductive admissions that discover nothing we didn’t already know, treat nothing that we weren’t already treating and, if we are lucky (because the hospital is a cess-pit of infection and risk) leave our most excellent and trusting patients no worse for the ordeal except for some familial inconvenience.

Reaching deep for my last reserves of courage my hand bypassed the keyboard going to the phone instead to discuss this very gracious and patient lady being treated for Parkinson’s disease with her neurologist and to arrange outpatient follow-up for the next day.  

Maybe one day I’ll tell you about the Bell’s palsy patient I sent home with no lab work or imaging of any kind.

I am a thrill-seeker.  Too bad I’m going to get sued one day and decide that my financial well-being is more important than being a good and faithful steward of your treasure.


This country has changed, even in my lifetime.  It used to be a place where people worked and were proud of it as we were proud of out heritage as a pioneer nation, a place were prospectors, inventors, roustabouts, gamblers, swindlers, preachers, cowboys, investors, soldiers, pioneers, farmers, and every variety of people striving for their livlihoods could succeed or fail by their own skills and on their own merits, allowing always for the confounding hand of fortune that sends the river to wash away even the best-tended plantation.  It was a country to which my father came with nothing, expecting nothing except opportunity, and for which he had a great love that he instilled in me.

And now we are to be nothing but Belgium.  A lot bigger but Belgium just the same.  Nothing but another decrepit European social welfare nursing home whose sole pre-occupation is now to become the incessant struggle for money to support a growing class of people who have been seduced by the Obamatariat into giving up uncomfortable and often treacherous liberty for the long, government-cheese induced nap of the nanny state.

It should bother you.

My New Ride

As some of you know, I am a mountain-biker and I just thought I’d share a picture of my new ride.  It is a Specialized FSR XC Expert.  My first mountain bike was a 1992 Bridgestone MB-4 and while I recall it was a really nice bike, this one has front and rear suspension, hydraulic disc brakes, and weighs less than many top-of-the-line road bikes did back then.  There are no mountains in my state.  Nevertheless we have plenty of trails, ranging from smooth beginner level to heart-in-the-mouth-take-your-eyes-off-the-trail-and-you-die technical stuff.   I tend to ride a combination of paved roads, dirt roads, and the occasional rough terrain and since I can lock out the suspension for hills and really smooth roads this bike suits me well.  Yeah, the guys in spandex pass me all the time but they can’t really go off the road much so I don’t mind.

I used to run but got tired of it.  Twenty miles on bike is more fun than five miles on foot.

18 thoughts on “State of Fear

  1. Hey Panda,

    I am currently attending a very liberal arts college- you know, the ones where they regularly screen vagina monologues and the student body functions like a small ivy-laced North Korea. I was curious as to your opinion on Fox News- what do you think of it, specifically regarding how they are treating Obama’s health care plan? BTW I voted for Obama- and I am starting to wonder why…

    (I love Fox News. They are treating President Obama (and his health care plan) the way he needs to be treated, that is, with a healthy degree of skepticism. Or is “dissent the highest form of patriotism” only when a Republican is President? What irks the left about Fox is 1) It’s popular and regularly creams the other news networks in ratings (the only people watching CNN now are stuck in airports), 2) it presents, through its stable of covservative pundits like Brit Hume, a common sense conservative voice that has long been drowned out of the media, and 3) it is unabashadly patriotic and pro-American. Consider also that while Fox has a conservative slant, this doesn’t mean they are wrong or that the left is right. The other news networks have, for their part, jumped the shark with Obama. When you have Chris Matthews felating the president and CNN showcasing a group of students singing patriotic hymns to their Dear Leader maybe we need more networks like Fox. -PB)

  2. PB,

    I love your blog and TMR.

    Can you comment on the following?

    “In traditional medical ethics, the governing principle, according to the ancient Hippocratic Oath, is to “do no harm” to the patient. In modern utilitarian bioethics, the guiding principle is to produce “the greatest good for the greatest number,” whether that good benefits the patient or not” Quote from:

  3. Stephen Furlani : I’m pretty sure I know what Panda would say to your question. Basically, when it comes down to it, those ideals are not the usual way to make a decision. Shorter term, more practical goals are what he keeps in mind. And the system overall doesn’t care about these ideals either, it only parrots them as lip service.

    (Exactly, while I have a decent regard for society most of my decisions are made on the basis of two criteria: What’s good for me and my family (generally) and what’s good for the patient (professionally). I am as selfish and self-centered as anybody but, paradoxically, a society structured to encourage individual intitiative, enterprise, and rewards is always more prosperous and stable for everyone than a dreary collectivist dystopia. -PB)

  4. ” I am as selfish and self-centered as anybody but, paradoxically, a society structured to encourage individual intitiative, enterprise, and rewards is always more prosperous and stable for everyone than a dreary collectivist dystopia.”

    Right, that’s why we bailed out Wall Street, and now they have record profits.

  5. I don’t know about Belgium, but I’ve lived in France and Netherlands. We’re not them. I loved living in both of those places, and I much prefer their society to ours, and I hope one day we’ll get there.

    Not even close to being there yet, unfortunately.

  6. Mountain biking is meditation for Type A’s. Gotta love it. Traded my Specialized for a Yeti and no regrets…

  7. I whole heartedly agree with your sentiments about where the country is headed and I have myself have preached the fact that it should “bother you.” The question I have been asking myself lately is what are we to do about it? What can I do about it? The age old line of well, we all have a vote, or write your congressman is about as useful as the American dollar right now, which coming from someone who has been in Europe for two months isn’t much.

  8. Interesting…

    Fox (and by Fox I mean the trifecta of irrationality: Hannity, OReilly & Beck) irks mOrcor different reasons (mostly from a spiritual standpoint- I am atheist) I agree that dissent is the highest form of patriotism, and it seems like msnbc & CNN jumped on the Obama train… But to echo what you said, I think we can agree that all the networks participate in bipartisan hackery. When the networks overlap with politics, though, then the news can get framed differently- I guess what I am trying to say is that it is politically expedient for Fox to rag on Obamarama’s Reform Coup d’état, just like it’s politically expedient for the Corporate News Network to never have any coverage of antitrust laws because that goes against the Monopoly model of business. Of course Fox will cover news tagging Obama! The demographic that watches it are mostly conservative. I used to be an avid watcher of CNN before I began thinking about where my news was coming from. Unfortunately, in the PC charged atmosphere of liberal arts college, my latte-liberal spoiled rich-ass peers don’t even know the definition of dissent, perhaps with the exception of the occasional benign facebook status update.

    I am 19 and I am already disgusted with the ignorance of most of my generation.

    Sorry, I digress, I forget this is your blog, not mine, but I’ll end on a different note- I am tryng to weigh dental school vs med school. I hear with the uncertain future of healthcare in the US, an MD may not be the best choice nowadays. What are your thoughts on that? Thanks, and I really appreciate your responses and and your vigorous critiques of medicine. –/B\–

    On another note,

    (Conservatism is a well-developed, intellectually consistent philosophy. The kind on screeching, victim-based collectivism espoused by every other major news network is not. It is not a question of moral equivalence. You may not like Rush Limbaugh or Glen Beck but they are right about most things, including the general premise that the decline of the West is almost exclusively the result of leftist insanity. I won’t even dignify the CNN and PBS crowd with the term “liberal.” Heck, as I am for individual freedom, personal responsibility, free markets, and respect for the law at all levels of society, I am a “liberal” myself. It’s just that that these views are so far to the right of what our hereditary elite believe that they call them “right wing” and I use the term “Conservative” as short-hand. On another note, the efforts of the Obama administration to silence its critics on the Right should be deeply disturbing to everybody. -PB)

  9. Brett,

    FYI dentists and orthodontists are getting their asses kicked right now; people are having trouble paying out of pocket for services, which is a huge part of dentistry.

    Although there is turmoil in medicine right now, it is about the safest field you can go into as far as job security and money go. You can outsource just about anything except your doctor.

  10. Point of clarification- could you define “victim-based collectivism” with respect to your overall thesis that most of the problems in America come
    from left wing insanity?

    I agree with your point on you being “liberal”, in the classical sense. I haven’t read your blog enough to be informed on this, but what exactly about the far
    left pisses you off? For me, it is the effeminate political correctness that censors free speech.

    BTW Oreilly, Glenn Beck, and Rush are dumbasses who really don’t know what the fuck they are talking about. I am 19 and I factcheck every episode of O’reilly & Beck, just for fun, and even some casual research gleans some glaring mistakes. I never said I don’t like them, however. I just don’t agree with them.

    As always, I appreciate your responses.


  11. Panda

    Help me. I have been broken by the customer satisfaction system.
    I recently evaluated and treated a patient who presented with a migraine. Upon arrival she directly requested Demerol to the nurse and myself. I gave her a medical screening examination and treated her appropriately with medications that did not include Demerol. She left unhappy claiming she would not be paying for the visit since she did not get what she wanted.
    Fast forward one day – She arrived to our other facility where to her surprise I was again her treating physician. No Demerol. The patient made a scene which required some response from me. She left and appeared unhappy – Oh well
    One week later an official complaint was filed by the patient and I was asked to apologize.
    I feel that my spirit to do the right thing is second to retention of “Customers” and “Customer Satisfaction”. When a patient gives me a compliment I almost want to ask them to make sure to give me good ratings on my care evaluation. I feel like a car salesman. Is that where we are headed?
    Maybe universal healthcare will remove the customer incentive and take us from Car Salesman and customer back to Physician and Patient where our intention is to always do what is in the patients best interest and not whatever they want to avoid low satisfaction scores. The last time I checked patient satisfaction scores are not synonomous with good medical care. Some of the nicest doctors are bad practitioners.
    Your thoughts???

    (Dude, I wouldn’t apologize. I would offer my resignation if they insisted. I know you and I know you could get a job anywhere. Demerol is not like insulin. Holding it from a patient is neither a breach of the standard of care nor is it harmful to the patient in any way or legally actionable. If I did apologize, the extent of my apology would be, “I’m sorry you were unhappy but I will not give you Demerol or any dangerous and highly addictive narcotic unless I think it is clinically indicated. Your asking for it is not a clinical indication.”

    Like my attendings always told me, on the other hand, never get into a pissing contest with a patient. I have, by the way, had several similar encounters. Stay strong.

    She will most certainly pay for the visit. Nowhere in any agreement signed by the patient are they promised anything more than evaluation and treatment as the doctor sees fit. I assure you that if your hospital lets this patient get away with not paying it will open up the proverbial floodgates of people who will likewise not pay if they don’t get a “shot” or whatever treatment they think they need regardless of what they really do. I would throw this back to your administration and admonish them to reach down and grab their testicles or lose them in the future. -PB)

  12. Panda, I know you said not to get into a pissing contest with patients, but could you elaborate a little more on this statement? Thanks in advance dude

    (I mean that you should never argue or even negotiate. If you’re not going to give narcotics then make a decision and if the patient doesn’t like it, firmly but politely reiterate your decision, stand up, thank them politely for their patience, give them a few parting words of discharge instructionage (“Remember to come back for those things we discussed and call your doctor tomorrow morning”) and then, like dipping a chip (for you Seinfeld fans), just end it. Don’t stay in the room, don’t argue, and don’t rationalize your decision to the patient. I pretty much just discharge them after my final re-evaluation with no prescription for narcotics and, if they have a problem with it they can ask the nurse to speak to me. Most know that the jig is up and leave without demur. I don’t always follow my own advice but I am getting better at it.

    Two points: Everybody should get the benefit of the doubt but Demerol is never indicated for anything. It is one possible choice of about a hundred pain medications and a patient who asks you for it specifically (or any narcotic) is a druggie, no douby about it, and just looking for the high. Real Migraine patients, for example, are willing to try anything and are not fussy. Benadryl? Reglan? Valium? “Whatever you think will work, Doc.”

    It’s the druggies of whom I am growing weary who look at the Emergency Department as their narcotic buffet.

    Point number two, we are not obligated to give the patient what they want over what they need and it has not yet come to pass in our truly insane society that we must. It is impossible to get sued for not giving Demerol or any other pain medication for Migraines because the literature supports the sparing use of narcotics. I fear sending home an abdominal pain or a chest pain but never a Migraine patient who is having their typical Migraine and has been worked up extensively for the same even if their pain is not completely resolved. I also want to point out to you druggies that I don’t believe your pain is twenty-out-of-ten when your vital signs are completely normal. Impossible.) -PB)

  13. Panda could you please recommend some of those little pocket books that medstudents should carry? I’ve heard a pharmacopedia is good but not sure what else. Thanks for everything

  14. Hey Dr. Bear. I’ve followed your blog for about a year (though I’ve never commented) and I would like to thank you for your hard-earned wisdom.

    I’m set to start medical school next year (class of 2014) but am having some serious doubts. I know that there are more lucrative, easier to finish careers (law, business, perhaps dentistry)but I’ve always been set on medicine. I just don’t know if i’ll be able to take the stress of residency and 3rd year medical school.

    You say that you would not have become a doctor if you knew what you know currently know. However, part of the problem may be that you have a family and are a non traditional student. Since I’m 23 years old (2 years behind my peers but still young), it should be more worthwhile? Thanks….

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