CYA and Healthcare Reform

September 27, 2009

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.

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Some People Have Nine Lives Too

July 12, 2009
Medical Cynicism 101

Medical Cynicism 101

I remember someone giving me a book to read called The House of God when I was in medical school. I imagine that a lot of you have read this book as well. I thought that it would have been a better book had it not digressed so much into sex and I never really finished it for that reason. Looking back now at the some of the book’s ideas, especially that of the GOMER, a lot of it really rings true.

There are certain people that come to the ER that seem to command little to no empathy from all ER staff. They go by different names but they seem to make their way to all ER’s irregardless. They just don’t die, no matter what they – or someone else – does to them. They survive such extreme conditions that would kill even the most hardened average person a long time ago. And they just keep on ticking away.

I saw one such person in the ER this weekend. A staffer at the ED told me that he knew him well as he used to see him regularly when he owned a liquor store. The guy apparently had 6 kids with 6 different women (another f#^&er setting up franchises I noted), and was clearly proud of it when I asked him. This time, he was driving his motorcycle at about 100 MPH down the highway, weaving in and out of traffic, until he lost control. His bike slammed into the median strip ditch at this insane speed and he went flying into a field where he landed on his back. Of course, he wasn’t wearing a helmet. Would you or I have survived an accident like this? No. We would have died when the bike hit the ditch or even before that maybe. Did it kill him though? Not even close. He ended up with a broken collar-bone and first rib. He went home after a short observation period in the hospital.

Or not so long ago, when I saw a raging @$$hole in the ER demanding that I give him a prescription for ritalin. I had already looked into this guy’s long list of abuse (cocaine, meth, alcohol, narcotics, benzos, etc.) as well as the previous notes describing his charmingly prickish personality and habit of physically attacking those who disagree with him.  So, I explained to him as politely as I could (while maintaining a safe distance) that this was not something that we ever did and that he needed to speak to his doctor if he felt he should be on it. He threatened me and used enough profanity to make someone from the Sopranos blush, and then left the ER.

He was so angry at so many people that he decided that enough was enough and he was going to die. He took an overdose of someone else’s Vicodin and Xanax and locked himself in his room at the house he was staying at.

An hour later, one of his house mates came to check on him because he was “unusually quiet”.  No answer and so he broke down the door only to find his “friend” lying facedown on the floor with two empty pill bottles near-by. He tried to wake him up and then called EMS. They arrived within 5 minutes – 5 minutes where no one was doing any CPR on this 37 year old man. He had to have been dead for at least 30 minutes before EMS even layed hands on him. They worked him for 15 minutes with nothing and brought him back to me.

In the ER, we worked him for another 20 minutes and just before I called time of death, wouldn’t you know it – his heart started beating again. I really don’t know what happened to him eventually, but how could a man who has been totally dead for at least 30 solid minutes to one hour get anything back is beyond me.

If it was some kid who had drowned in a pool and was given CPR by mom and then brought to us he would have been dead of course. Its the people that seem to be the most vile that survive. The ones that you hope make it are never the ones that do make it. Their stories are tragic. As for these people, I honestly believe that they are anaerobes like bacteria.

They seem to actually thrive when they don’t have oxygen or other elements essential to life for the rest of us. They fall off a building and the next day they are walking out of the hospital after they have drained the life out of everyone they have come into contact with – which may in fact be their secret. Maybe there is some truth to Vampires after all?

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Healthcare Administrator Salaries and the French Fireplace

June 5, 2009

stress salary

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.

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Death and ATV’s

May 24, 2009

Sorry for the recent absence, but I’m back now. And what better way to get back into gear after being on vacation than to work Memorial Day Weekend! I should have my head examined.

ATV – All Terrain Vehicles, or as I like to call them, four-wheeled death machines. I hate ATV’s and wish they would be banned. I have seen too many tragic consequences from them and think the risk-fun ratio is just way too high. I like to have fun as much as the next person, but when people start dying, we need to take a time out and reassess. My first bad patient experience was my first year out of residency when the respiratory therapist that i work with brought her son in DOA (Dead on Arrival) after he was riding behind his brother who hit a tree. Unfortunately no helmets were worn. This weekend though brought on more sadness.

23 year old woman, drunk, riding an ATV at night runs into a barbed wire line at speed. The wire cut into her belly, removed the right kidney from its blood supply (a big hose), lacerated her liver and spleen and cut some intestine. She went immediately to surgery and bled to death on the table.

30 year old woman, majorly drunk, riding an ATV in daylight and rolls it in a field. She suffers multiple spine fractures, lacerated spleen and liver as well and dislocates her hip. Ouch! She survives surgery, but quality of life after this accident will be questionable. She will have pain everyday for the rest of her life I imagine.

Please, if you read this post and either ride an ATV or know someone that does, make sure they always wear a helmet and that they don’t drive after even one drink. If you can send the whole thing to a junk heap to be crushed that would be even better. You can have fun in far safer ways. Have a safe weekend please.

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The Origin of Swine Flu?

May 13, 2009

swine flu origin

I need to contact the CDC to track down this kid for isolation.

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ER Waiting Times – How Lucky We Are

May 9, 2009

skeletonI recently told readers about an ER practitioner in another country down-under who had some amazing stories to tell. When we first starting comparing notes, I will never forget the question he asked me. He asked, “So do you guys make people with colds and sore throats wait in the waiting room for like 8 hours before you see them?” I can’t say that the thought has never crossed my mind (or that if it was legal, heck yeah I would do it).

But I told him all about the two devils (Press-Ganey) and their effect on ER practice in the US where now the patient was a “customer” and entitled to customer service. The thought initially bothered me and my colleagues quite a bit, but now that I have a chance to see it from the other side, I’m kinda glad that we took this road.

In some ER’s in Eastern Europe, if you show up at night with anything less than life threatening (it won’t kill you in at least the next 45 minutes) there have been confirmed reports of the docs telling the patients to wait until they finish their coffee and vodka. Just hope they won’t be suturing, right?

Or in some parts of the Far East, if you are over 75 years of age, then your services will be cut back. One of my teachers in residency used to always refer to people over the age of 70 as “living on borrowed time” due to the average life expectancy. In these countries though, they take it a few steps further and essentially send the message, “hey, look you had a nice life already! Don’t fight it and go easy.” Seeing the way people are “surviving” in Nursing Homes though and the abuse they not uncommonly receive, it makes me wonder about my own wishes in this regard.

When talking about waiting room decor though, US ER patients really have it made. Free, and usually fresh, coffee; a TV to keep you entertained (wide screen plasma in many places now as well) and magazines arranged in a nice semi-circular pattern. Believe it or not, at the University of New Mexico they even hire a live harpist to “soothe” people as they wait. Try waiting in some ER’s elsewhere in the world where you might get malaria, suffer poisoning from the free coffee (or maybe that wasn’t coffee after all), waiting outside in the elements, or being told to go out and buy your own gauze and supplies because the hospital ran out.

So, the next time you have to wait a few hours in the ER to get your sore throat checked out, or to “check” if you are pregnant, just remember the alternatives. At least you will be greeted in most cases by people with a smile (damn you Press-Ganey!), all efforts will be made to get you well and your doctor will be relatively sober.

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Hydroxycut and Fad Diets

May 6, 2009

little_girls_smallA sad day in dieting occurred late last week with the pulling of Hydroxycut – the famed dieting pill (as seen on TV). The FDA is now warning consumers to immediately stop using Hydroxycut.  Apparently, Hydroxycut has been  associated with a number of serious liver injuries ranging from jaundice and elevated liver enzymes, an indicator of potential liver injury, to liver damage requiring liver transplant. One death due to liver failure has been reported to the FDA. Other health problems reported include seizures, cardiovascular disorders, and rhabdomyolysis, a disorder of muscle cell destruction that can lead to kidney failure.

Of course, news like this thins out the competitive field a little bit. True there are still pills out there on the market that promise that you can eat all the Twinkies, Hardee’s thick burgers and Oreo milk shakes that your heart desires without a nanosecond’s worth of exercise. For example, there’s always Alli – the non-prescription strength version of Xenical – which promotes weight loss by decreasing absorption of fat by the intestines, thereby reducing the number of calories you absorb. It also gives you diarrhea and nasty farts that leave skid marks in your underwear. And that’s on a low fat diet. Try that Hardee’s heart attack burger while on Alli and you my friend will understand the true meaning of pain while you spend the next 2 hours on the crapper.

By the way, did you know that the name of the man who popularized the toilet was Thomas Crapper? The guy who actually invented it was Sir John Harrington, hence the usage of “going to use the John”.  Ah, but I digress.

Losing weight is easy and it is hard.  To lose weight you need to eat less calories than you burn – easy in concept, hard in practice. One can also increase their activity level and decrease the amount of calories they consume and they will lose weight.But that won’t keep people from trying to find the magic lazy bullet which allows them to do nothing, eat anything and still have a beach bod. So let’s take a look at some popular, and not so popular, fad diets.

The Tapeworm Diet – Someone actually thought it would be good to eat one of these disease causing parasites. Hey, they’ll just eat all the excess food right? Wrong. Just like any pregnant woman will tell you, parasites eat what they want first and then you get the left-overs. So tapeworms get first dibs on your vitamins, nutrients and minerals. That’s why people with tapeworms usually develop ascites (big round pot-belly). I think I’ll pass thank you.

The Lemonade Diet – Popularized by Beyonce Knowles before filming Dream Girls, this disaster was originally called The Master Cleanser Diet by its creator, Stanley Burroughs in the early 40’s. Stan was a therapist once charged with second-degree murder after a patient died from one of his treatments. The diet eliminates toxins and “congestion” that have built up in the body, and because it doesn’t provide a complete source of nutrition, it is actually consider fasting more than a diet. Beyonce did lose 22lbs in 14 days on this diet, and the diet generally seems to have had good results with others who dare to try it either in Hollywood or elsewhere. Side-effects include lethargy, depression, dizziness, nausea, trouble concentrating, headaches and the one other one … oh yeah, death.  Use at your own risk.

The Paleolithic/Caveman/Stone Age Diet – The hunter-gatherer diet was introduced to modern times in the mid 70’s by a GI doc named Walter Voegtlin, with many variations since. Basically, if you can hunt it or collect it from a plant or tree, you can eat it. That means no dairy and no grains though. Hence the diet is essentially made up of  lean meat, fresh fish, vegetables, nuts, berries and fruits. No sugary calorie bombs or processed, preserved, cancer-causing excuses for food to fatten you up. Good for rapid weight loss in a healthy way but somewhat difficult in practice since you miss out on dairy and grains.

The ABS Diet – Newer kid on the block, created by David Zinczenko, the editor for Men’s Health. For many years most athletes and bodybuilders have applied the same basic fundamentals of the ABS diet to their dietary programs. These principles include eating often (5-6 times per day), a focus on building muscle, eating lean proteins, and striving to eat whole unrefined carbs.The Abs diet is made up of 12 ‘power foods’. One meal per week is designated as a ‘cheat’ meal – where you eat anything you want. The power foods are Almonds (and other nuts), Beans, Spinach (and green veggies), Dairy (fat-free or low-fat milk, yogurt, cheese), Instant Oatmeal (unsweetened and unflavored), Eggs, Turkey (and lean meats), Peanut Butter, Olive oil, Whole grain breads and cereals, Extra-protein whey powder and Raspberries (and other berries). It is a lifetime dieting plan with excellent results and a practical approach.

If none of these seem up your alley, here is one that I think we can all agree on every now again:

The Stress Diet:

This diet is designed to help you cope with the stress that builds up during the day. Breakfast

  • 1/2 grapefruit
  • 1 slice whole wheat toast – dry
  • 8 oz skim milk

Lunch

  • 4 oz lean broiled chicken breast
  • 1 cup steamed spinach
  • 1 cup herb tea
  • 1 small cookie

Afternoon Snack

  • Rest of the cookies in the package
  • 2 pints of  ice creamof your choice
  • 1 jar hot fudge sauce nuts, cherries, whipped cream

Dinner

  • 2 loaves garlic bread with cheese large sausage, mushroom and cheese pizza
  • 1 Liter of your favorite soda pop or cola
  • 1 bag of nachos with tub of hot cheese and salsa sauce

Late Evening News
Entire frozen cheesecake eaten directly from freezer

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