Reflections on medicine, drawn from a few shifts in the emergency room.

Where theory meets reality...

Where theory meets reality...

1)  If a specialist wants referrals of nice, insured patients, but answers my page with a drab, ‘what do you want now,’ kind of attitude, I can almost guarantee I’ll send the next patient to the doc who is interested and pleasant.  FYI.

2)  Primary care docs:  I understand your dilemma with pain medication.  However, it’s awfully easy to tell the patient ‘no more refills on narcotics for two weeks,’ when you know they have the option to go to the emergency department; and when, quite frankly, you know that they will go to the emergency department, to deal with their breakthrough pain.  If you think they’re scamming, call and tell me!

3)  Patients:  if your complaint has to do with falling off of the horse you ride regularly for recreation, why are you on disability for back pain?

4)  Nursing homes:  it’s a travesty that any LPN at a nursing home can send a patient to an emergency department, especially when their primary care docs so often say, ‘just send them to the ER.’  Case in point.  My partner, the inimitable Dr. Doug McGuff recently cared for a patient sent from a local facility with a complaint of ‘bleeding from scrotum.’  Turns out he simply had a tinea (fungal) infection, couldn’t help scratching (it’s a guy thing to begin with); and had nails as long as rapiers.  When contacted, the staff at the nursing home said, ‘well, his nails grow fast.’  Another way to limit costs in health-care.  Make folks just slightly responsible for ridiculous ER transfers that cost Medicare vast amounts of unnecessary expenditures each year.  Oh, and buy nail-clippers to prevent alleged scrotal emergencies.

5) In response to the widespread wisdom that we do a bad job with pain management these days, I say, ‘nonsense.’  In fact, far too many people are on far too many narcotics.  Why?  I guess because we can’t imagine that anyone would lie about their pain.  However, humans get addicted, and humans lie to get their drugs or sell them.  Like it or not, it’s true.  And the result is a national catastrophe of over-medication with narcotics, and addiction to those drugs among those who get them from physicians or buy them from patients.  One of our patients was recently arrested outside a pharmacy, selling the drugs he had been prescribed not two hours before.  I’ll bet his pain was a ten.

6)  Too many nights, I don’t have a pediatrician on call in my hospital.  It’s a travesty in a town with five pediatricians.  It’s insulting and demeaning.  Too many nights, I don’t have an ENT, despite having two on staff.  Too many  nights, I don’t have an ophthalmologist, despite the fact that their are four in town.  Too many nights, I have a patient that doesn’t fit anyone’s criteria for admission, but needs to be admitted.  Too old for pediatrician, too pregnant for hospitalist, complaint too neurological for non-neurologist; but our neurologists don’t admit.  Healthcare reform that seeks to increase access will not help if physicians aren’t accessible.  Right now, in a time in which increased work can in fact result in increased money, physicians are avoiding call in droves for lifestyle reasons.  Guess what will happen when their pay is cut and they are salaried?  When they make the same amount of money for lots of work or little work?  Are we prepared to force physicians to work under threat of punishment?  Do we want to be cared for by a physician compelled by law to work?

7)  I’m aghast that someone would dare to go to a local subsidized, indigent care clinic, obtain subsidized medications, and yet pay cash to see a chiropractor!  Is there no shame left?  This is what we’re facing, folks.  A world of people full of the expectation that they can spend discretionary money for desires, while everyone else meets their needs.  It’s madness, quite frankly.  And it should make everyone in healthcare feel scandalized and used.  Just as it should make that patient feel ashamed.  As if.

8) One of the most satisfying patients I’ve recently seen was a young woman with an abscess from IV drug abuse.  No insurance, but a very real illness. She was happy to have the abscess drained.  And followed directions to the tee.  And she wanted to find a treatment program.  It isn’t just the insured or ‘normal’ that make our work worthwhile.

9)  I don’t doubt that someone will say I’m burnt out and bitter, greedy and small minded.  But I’m just writing about what I see.  I’m writing about the ‘evidence’ that is patently obvious in the great morass of healthcare.  These truths are often difficult; but they are absolutely essential to an unbiased assessment of the problems in healthcare; which are much more complex than ‘insurance companies and doctors are greedy and anyone opposed to reform is heartless!’

Have a great weekend!

God bless you all richly.


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