CYA and Healthcare Reform

Ok, so I know that I haven’t written a post for some time now and you are about to understand why. About one month ago, my dad called me to tell me that his primary care doctor had instructed him to go to the ER immediately because his routine EKG showed a change from last year. She had in fact stressed him out to the point of probably giving him a heart attack with her behavior which included wanting to call 911 to take him directly to the ER from the clinic.

Was he having symptoms (chest pain, shortness of breath, diaphoresis, decreased exercise tolerance)? No. In fact, he felt totally normal. Was he having ST elevation or depression on his EKG (findings typical of heart attack or diminished blood flow to the heart respectively)? No. He had “nonspecific t-wave changes”. Were his vital signs concerning? No. His blood pressure was 128/72, heart rate was 88. So why call 911? Because the primary care physician wanted to practice CYA (cover your arse) medicine.

For some reading this post, the term CYA medicine might be something of a novelty. Certainly one never sees Dr. House, MD or Dr. Cox from “Scrubs”, or even Dr. Green and Carter from “ER” practicing this type of medicine. What exactly is this type of medical practice?

It basically involves the most limited degree of mental commitment possible in a medical encounter, where you are asking yourself only one question, “How can this patient hurt me later?”.  Based on the medical provider’s answer to that question, they then proceed accordingly. It doesn’t matter how much this will cost the patient – insured or not. It doesn’t matter how many needless tests you have to order at the patients physical, financial and emotional expense. It also doesn’t really matter if the patient agrees with you or not, especially if they are insured – because you can always threaten them with an AMA (against medical advice) discharge where their visit will not be covered by their insurance. They are your prisoner so you can strategize your defense from a medical malpractice lawsuit.

As an ER physician myself, I cannot always blame providers who practice medicine this way. I don’t believe that anyone graduates residency intending to practice medicine this way. Its after someone comes after you for something only God could have forseen that you get gun-shy. At the end, it becomes a vicious cycle of abuse from both ends.

This is the biggest problem with Healthcare reform – the hidden nooks that politicians can’t see the way we, as healthcare providers, see them from within. There are too many groups mining in the medical gold mine – malpractice lawyers, insurance companies, drug companies, etc. – and they each have powerful lobbies to back their interests. The purity and simplicity of the doctor-patient relationship with all that it used to contain of trust, friendship, understanding and forgiveness has been plundered and I personally am not sure we can return to that after having let in the greedy pirates mentioned above.

So, back to my dad. He asked me to come with him to the ER – in my car and not the ambulance – to make sure they didn’t rape him there with unnecessary tests and procedures. He had me stand behind the ER provider who was practicing CYA and give him thumbs up or down depending on whether I agreed with the management or not. They of course told him that he could die if he wasn’t admitted for “further testing”, but he did just fine at home until his next follow-up appointment.

Coping Skills Don’t Come in Pill Form

Just swallow

OK, I promise to write more often (thank you all for the kick). June and July are always mega-busy as everyone tries to go on vacation, and then you get a Dumass doctor fired and it just makes things that much harder on everyone.

One of the saddest commentaries on the modern world that I see on an all too regular basis is the absolute lack of coping skills in the growing generation. We had generation X and then Y, and I guess they’ll need to call this generation W for whiners. Too pampered while growing up that they have no idea how to manage their own problems after they very effectively create them.

Case in point. This past weekend, I had the unfortunate experience of seeing LT on three separate occasions for what he described as “anxiety or a panic attack”. LT was a promising college football recruit out of his competitive high school district. I have no doubt that he was getting his bum kissed all the way through high school and well into college until he blew out his knee.

He went to surgery for his ACL, but being that LT had always had others to take care of him, he ended up with an infected knee and a PIC line. The nurses in the ED came to know him well as he would often roll into the ER for his scheduled IV antibiotics after midnight while drunk and with a different girl on his arm. And things would only get worse …

Soon after, one of his girlfriends got pregnant and decided she didn’t want him in her, or the newborn boy’s, life. On one of his drunk escapades, he got into a fight with some guys on a street corner. For some reason though, he was the one arrested (they were all the same ethnicity by the way). Since his knee was no good now, he also lost his scholarship and with it, the stream of girls who had followed him around.

So now he had only one girl left and a growing list of problems. So poor LT thought he was going crazy and came to the ER. There he received an rx for Paxil and some Ativan to help him calm down. Little did I know that he would be back a short 10 hours later. He told the nurse that the doc he had seen earlier “hadn’t taken the time to talk to him”. He was surprised to see that it was still me though and quickly backtracked by saying that what he meant was that he hadn’t had enough time to fully explain his problems.

So, I listened patiently to him as he told his sob story. Afterward, I explained to him once again that he was not crazy but that he had several issues that he would need to address one at a time (just like the rest of us mere mortals). He didn’t seem to like my suggestion as that entailed actual effort on his part. I resisted the urge to ask him if his girlfriend wipes his butt for him as well.

The next day he showed up yet again, this time saying that he felt chest pain. I was obligated to do more of a work-up this time – which was completely negative 80 minutes and $5000 later. I had no desire to see him again in what remained of my ridiculously long shift and hit him with the B-52. When his mother, I mean girlfriend, came to pick him up he was already half-way to his “happy place”.

Thinking I was done, I actually rested. But less than 2 hours later the police showed up with an inmate who had swallowed shampoo and some toothpaste in a suicide attempt. I asked him why he had done that, and he said that he couldn’t handle being in jail anymore. He was put in jail 3 days earlier for DUI. I thought to myself, “you really don’t know what being uncomfortable is all about – yet.” Then I got out the gastric lavage.

I don’t think he had bargained on getting a garden hose put into his stomach without sedation. But he just couldn’t get it through his mind that he needed to find a way, other than medicine to “knock him out”, to cope with prison life. The whole “do the crime, do the time” thing just didn’t compute in his mind.

The future scares me.

Healthcare Administrator Salaries and the French Fireplace

A few days ago, I had the great pleasure to visit some good friends from the hospital for lunch. They are good, hard-working people; salt of the earth. It bothered me how hard they work and how they seem to get so little back for their work, and I mentioned that to them. It led us into an interesting conversation about how much the admin people are making at our local community hospital – I think I hurt my jaw when it hit the floor.

I am not naive when it comes to the outrageous salaries that health-care administrators (CEO’s, CFO’s, COO’s and all the other acronyms they make up to take more money for nothing) seek to justify to themselves, but most people tend to think of these overblown salaries as belonging to Wall Street types in big cities; not your run of the mill smaller town.

So, I was quite surprised to learn that the CEO at our hospital pays himself close to a half million dollars per year. All while cutting nursing hours, chastising docs about overtime hours and outright terminating other direct patient care personnel positions for “cost savings”. The CFO also gets a healthy paycheck, closer to a quarter million though. He once told the hospital staff that they always have to go for the best in patient care, kind of like when he couldn’t decide on importing an $80,000 fireplace from France or buying an American one for under 10 grand. He decided that he should go for the “best” and went ahead and imported the French one in the end. He probably should have ordered a mail-order brain and conscience while he was at it.

This prompted me to look into the whole issue of the hospital administrator fleecing of America. I found many intriguing details that just nauseated me in general, but none better then the following concise post written by Dr. Ira Kirschenbaum on his Mad About Medicine blog. I will quote just one paragraph here for your benefit:

… the next time you want to argue with your Primary Care doctor’s front desk about a $5.00 co-pay, remember that he makes an average of $149,000 per year. On the other hand — using United Healthcare as an example — your insurance company paid their CEO — one man — [324 million dollars] over a recent five year period.

He then goes on to list 23 health-care CEO’s salaries – mostly those of insurance companies and drug manufacturers – and their published 2005 salary as well as 5-year combined income. The “poorest” guy in the bunch, James Tobin of Cardinal Health, made “only” $1.1 million in 2005, but he had a good 5-year period over-all, making $33.5 million (or just under $7 million/year). Poor James, what ever will he do to keep up with the Joneses?

Inevitably though, discussions like this lead to some people praising the wonders of capitalism and warning against the evil of “socialism”. At the end of the day though, it is balance and moderation which saves a society.

Our hospital will certainly go down, as it eventually must with these crotch stains at the helm. At that time, I seriously doubt that the hundreds of people out of the job will be giving a damn one way or the other about political ideologies as they join the masses screwed out of their job by corporate greed as they try to figure out how they will put food on the table.