More on the 90 year old with cancer

Today the Happy Hospitalist extended an invitation to oncologists to edumacate him on whether there was any benefit to treating the 92 year old for cancer. Yeah, the one Dr. Happy wanted to drive to the funeral home. An oncologist (At least he says he's an oncologist. He sounds like an oncologist. He must be, right?) responded in the comments:

The Science of Extrapolation

Says Dr. Happy Oncologist:

I am troubled BY the rhetoric you put forth that a) chemotherapy invariably yields a miserable existence while you're going through it, and b) that metastatic breast cancer is as grim a diagnosis as other metastatic disease. Life expectancy can often extend past a year depending on the situation, and there is definitely a tail on that distribution . . .

. . . Am I extremely cautious about treating someone that old? Certainly. But do I dismiss it out of hand? Definitely not. And when you show me any double blind RCT that includes patients with IDDM and CHF as comorbidities (saving you from having to, yes, extrapolate data based on your best clinical judgement), I'll eat my words.

Amen. A gracious smack down.

Is Organic Food Healthier

Maybe not. Maybe you should save your pesos for a new pair of vegan shoes:

Organic food is no healthier, study finds

Shout out to Clinical Cases & Images for the link.

I think I have sciatica

Cool.

Whole Body Magnetic Resonance Neurography in Two Men, from NEJM

Elegy for the 90 year old

Image via Wikipedia

Dr. Charles, in his elegaic way, adds to the conversation:

An old woman?

Lovely:

"She walks slowly and deliberately, with a grace that only arthritic
joints and battle worn cerebellums can command – at once imperial as a queen,
and familiar as a grandmother. When she calls the women at the front desk “my
girls,” no one blinks, and despite her agonies she is rarely caught without a
smile."

The squid as stealth bomber; all bacteria talk

Consider this. You are mostly bacteria. You are covered with an armour of bacteria that protect you, live with you, are you! Consider that bacteria, if they really want to, can reduce you to dust AND that they talk about it RIGHT IN FRONT OF YOU with their own secret language. AND they all speak the bacterial equivalent of Esperanto and can communicate fluidly not only with members of their own species, but outside their own species. Not only can they destroy you, but they will outlive you. They will digest you.

Consider a squid with glow-in-the-dark cheeks.

Consider that a one-celled organism is smarter than Jenny McCarthy.

I digress.

Watch this fabulous lady at TED for as long as your nerd mind can stand it. Thank your lucky stars that she did her homework in high school and college and is out looking out for you and Oprah and Jenny, even though they don't deserve it. She is your friend, and so are bacteria. Although ultimately they will eat you. And that's a good thing.

Let the 92 year old die...Or not

Not sure if y'all picked up the exchange between Happy Hospitalist and Buckeye Surgeon this past week. It was disheartening. It all started when Buckeye Surgeon posted about a 92 year old patient he was consulted about to put in a port so that lady could get chemo treatment for her breast cancer. At first, Dr. Buckeye thought, "Ee gads, no way! Huh? NINETY-TWO????" But then he met her and thought, well, okay. She runs rings around some 50 year olds, she's realistic about her prognosis and how miserable treatment might be, and so, okay, I'll do the port. Here is his original post:

Tough Decisions

Dr. Happy picked up on this and vehemently (and predictably) went ah, apeshit. "No, no, no. She's 92. Let her go. She should die with dignity" (although she isn't in fact actively dying yet) "furthermore, taxpayers better not being footing her Medicare chemo treatment because it's just wrong, if for no other reason than her age." Here is Dr. Happy's post:

Should 92 year olds get chemotherapy for breast cancer?

Here is Dr. Buckeye's lovely response to Dr. Happy.

The Meaning of Life

Happy responds in the comments. Not suprisingly, most of Buckeye Surgeon's commenters disagree with Happy.

So do I, probably. The devil is in the details, as always. I would trust that the oncologist taking care of said 92 year old isn't giving her full-bore, rootin' tootin', megaton chemo, but more gentle, hey, there, slow down chemo. That's happens fairly frequently in OUTPATIENT medicine, but Dr. Happy doesn't see outpatients. Instead of potentially curative, kill-it-dead-and-hopefully-leave-the-patient-alive chemo there's a middle road, somewhere between pure palliative chemo and full-throttle.

Lots of people avoid hospital admissions completely during their cancer treatment, shuffling from office to office for chemo, radiation, consults, and diagnostic testing. Symptom management has become impressive, although certainly not perfect. Nobody feels great during chemo, but lots of people feel okay, especially between treatments. I've had patients who continued working. I've had chemo grandmas who watched their grandchildren so the parents could continue working.

I'm not nuts about Happy's line of reasoning, either. If you're just going to say "no" to every 92 year old cancer patient, why not every 50 year old smoker who needs a CABG? If they won't swear they won't quit smoking, then submit to drug tests to prove that they have, why not just cast them out of the fold? No more insurance, buddy. Good luck getting treatment, but hey, those cancer sticks automatically disqualify you.

How about babies? They don't exercise. Damn them. Lazy butts. No insurance. I just saw a little boy riding his bike in the street without a helmet. Damn him. I revoke his insurance because he practices a high risk lifestyle, and if his parents let him out like that they are irresponsible gits, so strip them of benefits, too.

If you've already had cancer, frankly it just doesn't make good financial sense to cover you anymore, so forget it. We'll treat you this once, then you're done. Dr. Happy, you have a very high risk job in a profession with a high rate of substance abuse and dependency. Forget your health insurance, and while you're at it, disability insurance, too, because statistically speaking, you aren't going to do well. Dentists? They all commit suicide. Forget it. We're taking their insurance away, too. Vets? They could be stomped by a horse in school. That's too much risk.

Nurses might get needle sticks. No insurance. Damn women tend to get pregnant and that costs ONE HELL of a lot of money, so forget it! No more insurance for women. Done.

If we strip babies; children who don't wear bike helmets; parents of children who don't wear bike helmets; anybody who has ever even backed their car out of a driveway without a seatbelt; anybody who has every used a hammer without safety glasses; all women, all health professionals, really; anybody with any kind of chronic disease; and anybody who's ever been sick, or might ever get sick (and you're ALL going to get sick and die, no matter HOW MUCH PREVENTION YOU PRACTICE) then think of the savings. We could all retire to the coast in Florida and await hurricanes while we work on our skin cancers.

Should your ass bleed when you sneeze?

I just watched this on DVR. Hilarious. Some classic lines:

• I've got bad news for you! Five out of five people are going to die anyway.
• All I heard was socialized medicine means less traffic.
• Your anti-health care anecdote is a "friend of a friend?" That's not even enough proof for an urban legend.
• If you can't give me any evidence, then at least do the honorable thing and confuse me.
• When you were growing up, people didn't talk about health care because they thought that they got sick from witches.
• That was my Spongebob! And he could have taught me to dance or smoke.

Watch and laugh.

The Daily Show With Jon Stewart	Mon - Thurs 11p / 10c
Back in Black - Health Care Reform
www.thedailyshow.com
Daily Show Full Episodes Political Humor Joke of the Day

A break from studying for a rant

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A new commenter (Hi, Nick) writes:

Do you REALLY believe the fee schedule has no influence on doctors?? Really? Does ANYONE buy that?

It's why primary care docs are so scarce these days, their reimbursement rates on the fee schedule are absurdly low, so med students became that swaggering heart surgeon who makes "oodles of money" instead. By the way, what patient could possibly afford that 3am CABG if our current trajectory continues?

First, thank you Nick, for stopping by.

But: I buy it. I live it. Well, I did before the hospital system that wasn't making enough money from me put me out of business. So yes, the fee schedule influenced me. It bankrupted me and stole my job out from under me. It influenced me--and more importantly my patients--in a negative way. Perhaps if I'd yielded to the pressure of botox and other cash-flavored ancillaries I'd still be in business. Or if I'd started biopsying every single skin thing I saw because biopsies pay a lot more than diabetes. But I saw the diabetics, just like most primary care physicians, and passed on the useless biopsies for benign lesions. I could have cooked the codes and made more money. I could have opened my schedule up for more high pay but low yield physicals. I'm not painting myself or any other physician as a hero. Most of us, I really believe (and observe) just do what's right.

I had a rather typical suburban practice with a high percentage of insured patients. Over and over and over for the last several years patients have declined these vaunted high-cost procedures the evil specialists are purportedly ordering. Patients with HSAs and other high deductible plans--which are the bulk of plans now--just don't have the money for their copay/coinsurance. Heck, I can barely afford my co-insurance. I had to work to convince most of my patients that the tests were necessary. I wasn't ordering them for any remuneration of my own. I made nary a cent. I ordered ultrasounds, colonoscopies, cholesterol panels etc because it was the right medical thing to do.

This of course, gives me an observational N of 1, but it's the same story I hear over and over from primary care doctor friends and acquaintances. Who exactly has this fabulous insurance which allows unlimited testing at no out-of-pocket cost to the patient? In my corner of the Midwest, in a big city with lots of hospital competition and pretty little women's centers and birthing suites, not too many anymore.

I can't say that I've run across many specialists who test gratuitously, either. When I felt as though a patient really didn't need a procedure a specialist was offering, I did my job and told the patient and the specialist what I thought should happen. I just wanted what I thought the patient needed for optimal care. The optimal care, of course, didn't make me a cent.

Frankly, I've been in practice a while, and I haven't come in contact with many evil, test-crazy specialists. On the odd occasion when I encountered a specialist who tested out the wazoo for no particular reason I moved along and referred elsewhere. I'd say that in my experience those tend to be specialists who move around a lot. It's difficult for them to manage a referral base because other physicians just like me move along and stop referring.

I'm not really all pie-eyed and idealistic about this. I just can't say that I saw a whole lot of pocket padding. The physicians I've worked with are far too busy actually taking care of patients to count all those pennies in their pockets. I'm suspicious that for the medical equivalent of ambulance-chasers, who I know are out there but just don't form the bulk of physicians in practice, they'll just find some new way to exploit the payment scheme.

I maintain, in any event, it's not the payments for highly skilled labor that is the heart of the problem here. Chronic disease, an aging population, profit margins stockholders demand from for-profit insurers, litigation, medical equipment, Part D, whackadoodle distribution of specialty hospital beds and services, I would suggest are also major players.

In any event, pay physicians less and be careful who is doing your CABG at 3am. Or following up three weeks later for a regular appointment. You get what you pay for. If your wheelchair needs to be oiled and tweaked to keep moving that's one thing. A crap primary care doctor ends up costing patients a lot more. A CABG redo, or a retroperitoneal bleed from a sloppy cath, or a major hernia repair from a slipshod primary herniorrhaphy ain't nothin' cheap.

I'm not really suggesting, either, that nothing happen. It's absurd in this country that every man, woman, and most especially children don't have basic insurance coverage. I am suggesting that the talking points I keep having rammed down my throat about evil physicians and how little effectiveness research we apply when making clinical decisions pisses me off. It's generalizing and I think it's wrong.

At heart, I really am a bleeding heart liberal. I'm horrified at the state of health care. I'm horrified that I'm not taking care of my cadre of patients. I'm outside the fold now, kind of, and I'm telling you that even looking in with my nose pressed to the glass, physicians are the good guys. They're the faces--along with nurses, physical therapists, scrubs techs, etc.--of healthcare, who will help you through the most personal problems of your life. Of your grandma's life. Of your child's life.

Dammit, Nick, you kept me from studying for my boards tomorrow for another 30 minutes. How dare you. But thank you again for stopping by.

Nicely done lecture on short term insulin usage

This gentleman's voice is quite reassuring.

Let me beat a dead horse. Where in the magical mythical comparative effectiveness cookbook is there going to be a recipe for helping with a 72 year old post-MI lady who needs a lot of hand-holding and education, along with some possible bilingual support? I'm not knocking the need exactly for clinical reference material in a nice, central, organized place (like the USPTSF website), but humans are so messy and so complicated. Which algorithm do you choose? Especially when your pay might be linked to one more than another?

Specifically, here is what I was thinking while I watched this video, imagining the time to whip something like this up in my past life in a busy primary care office:

• All of this patient education is paid for, if you're lucky, maybe once.
• None of the work this physician did developing a handout, none of the research, revision, coordination with other ancillary providers is reimbursed. Not one second.
• The reimbursement for the patient to come in, post-MI, and discuss coordinated care with the cardiologist, maybe an endocrinologist, to review handouts, to talk about symptoms, medications, side effects, etc? To review all this insulin stuff? To go over the handout, look at a blood sugar log? To talk about what happens moving forward? If you're lucky and document and code well, say for Medicare $70 and a little change. It's pretty easy to pour an hour into a diabetic who is new to insulin AND who just had a heart attack, most especially if you include staff time. Take out the electric bill, staff salaries (JUST salary in my office for my staff was about $30/hour), malpractice, benefits, supplies, blah blah blah, I think you'll see that the battle is lost.
  

And no magical effectiveness cookbook of medicine is going to make it up.

I'm not suggesting that we ignore the recent frenzy associated with healthcare reform and do nothing, but if I hear about effectiveness research saving my patients, their money, their employers, and the entire country one more time I'm going to open up a can of whoopass and burn my malpractice insurance bill (okay, my malpractice is covered by my employer, but you get the point) on the steps of the White House.

Here's the link, anyway, courtesy of Clinical Cases and Images:



Nice job, Dr. Brill.

And here is his rather nifty handout:

Short Acting Insulin: Give it a TIE

Just in case anybody is keeping score, I'm not studying for my boards, so if I flunk, it's the blog's fault.

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• White House Official Links Health Care Plan to Fiscal Balance (nytimes.com)
• Cutting Health Care Costs by Putting Doctors on a Budget (time.com)

Happily ever after with a side of tabasco and a spritz of lime

This is fabulous. Thank you Dr. Green Thumbs for sharing the link! At the beginning I thought, Oh, Lord, how hokey, and by the end I was crying. Oh, I hope these two make it. I'd love to be a kid in their house! What fun. Good luck Jill and Kevin.

Okay, I'm calmer.

Here's a nicer, more positive piece from the always excellent and dispassionate Clinical Correlations:

Much Ado about Comparative Effectiveness

Still, however, what one finds in the actual practice of medicine on individuals, rather than populations, is that patients often forget to read the textbook. They don't respond as they are supposed to respond to prescribed treatments, or they present as diseases are described in medical tomes. They often fail to have the comorbidities that would lend themselves to straightforward management.

Argh.

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• Primary care doctors face burnout, and how that affects health reform (kevinmd.com)

Wow. I'm so pissed I'm removing my Obama bumper magnet.

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Here's what I heard last night and read today, with my commends:

We wanted to make sure that doctors are making decisions based on evidence, based on what works (We do when we can, but it's not usually that simple). That's not how it's happening right now (Yes it is). Doctors are forced to make decisions based on a fee payment schedule that's out there (In primary care mostly about how to get paid so you lose LESS money and how to take care of a patient cheaply). So they're looking... if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, "I'd make a lot more money if I took this kids tonsils out."(You completely, utterly do not get my job taking care of America's beloved families.) Now that might be the right thing to do, but I'd rather have that doctor making those decisions based on whether you need your kids tonsils out or whether it might make more sense to change, uh, maybe they have allergies or something else that would make a difference (Yeah, it never, ever crosses my mind to run through a differential, review of systems, or physical exam to figure out what could be making the patient's throat sore.) . So part of what we want to do is free doctors, patients, hospitals to make decisions based on what's best for patient care. (Oh, sweet Jesus.)

My husband screamed at me from the t.v.: "Hey, the President says you take out too many tonsils!" Oh, really? I'll bet I paid off my student loans with all that money I made from tonsillectomies. Oh, wait, I don't get paid for tonsillectomies and I still haven't paid off my student loans.

Mr. President. I voted for you. You let that kinda offensive crap be issued from your lips again, however, and I'll vote for Rush Limbaugh before I pull a lever or push a button or darken a circle for you again. I would NEVER dream to insult your professional integrity in such a way, even though, as it turns out, lawyers take their bar exams once and never again must fork over $1500, study for months on end, and sit in front of a computer to regurgitate everything you're supposed to know on a daily basis without the benefit of LexisNexis to help you. I am doing that tomorrow, then I will repeat it in 10 years.

Your example is absurd. It fundamentally misses the mark about what happens in the real world of primary care. I don't remove tonsils. When I do recommend they are removed, based on the best evidence, I don't make a cent, not one cent for the trouble. They go to see a specialist for that. The specialist doesn't send me flowers, doesn't take me out to lunch, doesn't promise me a vote, NOTHING. They just take care of the patient. You insulted them, too, by the way.

When I am forced to adjust the management for a patient, 99 times out of a hundred it is to find a cheaper way to get something done. My mostly insured patient population can't afford the copays and coinsurance they have for testing, procedures, hospitalizations, etc. I am continually striving to find a cheaper, EQUALLY effective way FOR THE PATIENT (those damn patients forget to read the effectiveness research) to get a job done, using less medication and more outpatient contrivances to forstall inpatient procedures and hospitalizations. That you assume that I--and most of my primary care colleagues--are managing patients based on fee schedules is appalling. I am speechless. Almost.

That you think medicine boils down to effectiveness research is absurd. That you insult my intelligence and patient management skills is horrifying. That you think effectiveness research is going to make much of a difference in primary care is laughable. Spend a day working with an primary care doctor. Try and apply one, just one algorithm to a depressed 67 year old who is diabetic in the middle of a panic attack, with pneumonia, mild dementia, unsupportive family, and who has $10 for medication to last her till the end of the month. If she eats cat food, that is. I've done that. Have you, Mr. President? Which page of the magical medical effectiveness cookbook is that on?

Argh. I seriously want to pack it in. Why bother struggling? Why study? Why bother doing unreimbursed chart work and phone calls for hours? Why worry about patients and their freakishly complicated problem constellations, problems which never in a million years could be addressed by effectiveness research? Open up the damn magical medical cookbook I keep hearing so much about, Mr. President, and do it yourself, if that's what you think. Good luck.

Say it, Sista

From #1 Dinosaur today:

The more I know about the patient who has the disease, the better job I will be able to do caring for that patient. How better to get to know the patient than to describe him or her as fully as possible right from the start of the encounter. For those who worry about stereotyping, allow me to offer the following suggestion: ask the patient to describe him or herself, and then include the response in the opening statement. Like this:

This is a 50-year-old white female physician blogger with grown children and way too many animals at home who describes herself as "zaftig but generally healthy."

I don't treat diseases. I treat people, and because every person is different, I think it is better to err on the side of more description rather than less.

This all came up apparently in a bioethical debate about the standard history and physical format, which almost always begins, "A XX year old (race) male/female (optional: occupation) who complains of blah blah blah. If a colleague says to me, "Hey, I just saw a 56 year old white construction worker who is here complaining of the worst headache of his life" I immediately switch into my doctor listening mode. The very way the beginning is worded sends me into my uber-focussed trance-like state. The convention of the presentation, the routine, the habit; the specialized, stylized way of speaking, almost its own language, immediately causes me to think in a certain orderly way, to start putting up salient points on my mental white board (right next to the list of things I need to pick up at the grocery store on the way home). Knowledge is power and the more of it I have about a person, the more I can think about him or her as a person.

The debate (post here) is about whether another physician is predisposed to judge somebody by the opening line, like, "The patient is a fat, slovenly, lazy, 'ho, about 26 years old, never worked a day in her life, covered with track marks, whose race is indeterminate but who smells like major BO." Yea, that would probably predispose me to think a few things, some of them about the deliverer of the presentation, some of them about the patient.

I want to know as much as I can, but not what the physician thinks about the patient untiil the end of the presentation, under "Impression and Plan". Even then I could care less about slovenly and backasswards comments. I'll make my own judgements. But I do want, it does help to have a picture of the patient in my head beyond a list of lab values, physical findings, and diagnoses. You never know, either, what will be relevent down the road.

Furthermore, reading a history that begins with something interesting, or that presents a little nugget that makes me giggle will predispose me to love the the patient nearly every time. For example, today I opened up the EHR on a patient and prominently displayed, right on top of the page under allergies was:

Dirty Girl (itchy lather)

That cracks me up!

Anyhoo, here's my stab at presenting moi:

40-something, and don't get more specific than that, pale, extremely well-developed and wildly well-nourished, opinionated, frank, tired-appearing physician who appears to have bacon fat on her shirt complains today of violent, homicidal ideation towards a lot of laundry, which she specifies had stains which were "taunting her" to use bleach.

Empty your dishwasher

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Read this from Happy Hospitalist:

In the eyes of Medicare, you are nothing more than a 99223.

In my world, you're usually a 99201- or 5, 99211-15, or any one of ten preventative codes, plus or minus a V-code, the odd E-code, G-codes, oh, and then there are a whole world of consult codes, PLUS there are procedural, or CPT codes for anything I do for you in the office, like a throat swab, pap smear, vaccine (oh, don't even get me started). Now, read Happy's note and imagine going through this math on every, single solitary patient you see, every single solitary time. You have to include everything you're done. You decide whether you meet the 1995 or '97 guidelines. Should you bill on time or complexity? Don't forget all the procedure codes for every little thing you did, and don't forget to attach them to the correct diagnosis, or ICD9.

I'm not kidding. Every patient, every time. And do you know what the consequences can be for me if I do it wrong? Not JUST that I don't get paid. I could go to jail. Prison. Where I'd crochet ponchos instead of seeing patients.

So imagine you're the doctor today with a patient who has a typical constellation of problems, say, diabetes, high blood pressure, and high cholesterol. All under okay control, but you need to check some labs today, and that pesky patient is complaining of a few little aches and pains in her feet which are kinda new. Now, you and your staff have to check the patient in, get her in a room, review her damn smoking history every time, talk about all her existing problems, talk about new problems, do an exam, get labs, get pee, figure out what to do, write a chart note, write out prescriptions (Oh, what's that? 30 day AND 90 days scripts for everything?) AND you have to figure out what to code. In TEN MINUTES. Times 20 or 25 times a day.

Does it take you 10 minutes to empty your dishwasher? I rest my case.

Slim blog pickin's

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'Cause I'm all about studying for boards. And work. And laundry.

But I came across this today. I was in a hurry to get back to studying (that's a joke) for my boards (on Friday, God help me) but found the article so compelling (that's not a joke) that I couldn't stop reading. Then I read it again. I read David Gorski, aka Orac every day, but this is one of his best. Powerful and informative. Even if you don't get it all, you'll get a sense of the math your doctor is doing when he or she asks for an MRI, colonoscopy, mammogram, or when you ask. I have nothing to add. He's amazing. I'm not sure he ever has time to shower, but keep bringing it on, baby.

Are one in three breast cancers really overdiagnosed and overtreated?

Wow.

"Being 13 and being told you'll never see again is pretty tragic news"

I must stop whining. Check out this remarkable young gentleman:

The Student

Lovely images from a NYTimes photographer of a lovely man who can't see them. Watch the video--only four minutes--and watch how confidently he moves. Then close your eyes and try to pour yourself a drink and consider what he's done. What you could do, if you had to. To borrow from Shakespeare, that man is a piece of work.

"BMI Sucks," says NPR. And it's funny, so I'm posting it.

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I have long wondered about this formula. Why is height squared? Who made this up? Why am I using it? I wonder no more. I have seen the light. Read on, MacDuff, and learn:

Top 10 Reasons Why the BMI is Bogus

Argh! Sure, BMI is a measure that's kinda sorta been validated, but it's far from perfect and shouldn't be used as a bludgeon to keep people away from donuts or lower insurance premiums. I see a fair number of very healthy, very muscled individuals in my new line of work. I mean, their cholesterols are nearly the same as a newborns baby's. Some of them run miles, then do stairs, then weights, then yoga, then run a few more miles, then swim a few laps in the pool. (Yes, yes, I'm exagerrating a little, but not much.) And they have muscles as big as my car, not one ounce of fat on their perfect frames, but sky-high BMIs. And don't you know our little handy EHR spits out a little blurb with a handout about how the patient should be counselled about weight control, soley because it figures out their height and weight and plugs it into the formula. If I were one of those big, fit Olympians, and my doctor handed me a little sanitized ditty written by committee about how I need to exercise and eat right, I'd sucker punch 'em.

Anyhoo, read and decide for youself. The comments--I only browsed through a few--were rather whiney or lectury so I'd skip them and not feel bad. But that's just me.

If you want to eat your heart out, you need to know where it is

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I am all about partnering with patients. It's easier, actually, in academia where I am now because I can use big guns like "extrapolate," "regression to the mean," "t-tests," and "antecedent" with PhD students and they don't look at me cross-eyed in a bit of a panic. They just look bored while they're waiting for me to get to the point and hand them a prescription.

If patient understands why and what you're thinking it's a lot easier to get buy-in. It's a lot easier to get buy-in if the plan takes into account the complexities and variables in the patient's life both while working on a diagnosis and/or treatment plan. It's more likely that if the patient feels as though they're a part of the process he or she might actually be compliant with the plan.

But here's the thing. It's the rare patient who knows more than I do about the practice of medicine. Rare. Very, very rare. I'm still stumped every day about something, and I've been at this for a while. I'm not the sharpest tack in the MD box, but my point is by no means dull. Physicians don't agree on a lot of things. And most patients don't know the most basic things about themselves, like "Where's your heart?". Take this tidbit:

John Weinman led a team of researchers from King’s College London who aimed to update a similar survey (ed: about basic anatomy) carried out almost forty years ago. He said, "We thought that the improvements in education seen since then, coupled with an increased media focus on medical and health related topics, and growing access to the internet as a source of medical information, might have led to an increase in patients’ anatomical knowledge. As it turns out, there has been no significant improvement in the intervening years".

The Google University College of Medicine isn't quite ready to start churning out graduates yet to practice on the internet citizens of the world.

The 722 people who took part in the study were shown pictures of the human body (male or female) with certain areas shaded out and were asked which of the shaded areas was the location of a given organ. Although 85.9% of people could identify the location of the intestines and 80.7% knew where the bladder could be found, only 46.5% of people correctly identified the heart and 68.6% misidentified the position of the lungs. Overall, approximately half of the answers were correct. There was no significant difference between men and women, although women did perform better when a female body image was used.

Okay, so you're me. You have 10 minutes in an appointment to talk to a patient about how it's going, to bond, to make nice. You have to extract the information you need, too. Information vital to managing the patient, whether the patient is interested or not in participating. (In fact, this part is usually easier if the patient is interested.) You have to do an exam. You have to formulate a plan, write it all down, write out prescriptions, order labs, review anything from before, talk to your nurse, and, of course, work it out with the patient.

Say it's just a cold. Fine. Easy. Ten minutes is plenty of time 'cause probably there aren't a lot of labs involved and follow-up isn't really necessary. But let's say you're typical of about half the patients a primary care doctor sees in the office. You have diabetes, you haven't seen an ophthalmologist in over a year (Uh-Ho! The insurance company is going to ding me!), you just turned fifty so you need a colonoscopy, your blood pressure is too high but your sodium on your last lab was too low, your cholesterol medicine made your liver functions bump, and we haven't even gotten to why you came yet today, which was because your back hurts! Your ten minutes took 30 minutes, which cut into the cold and poison ivy I had piggy-backed before and after your appointments for catch-up. So those people are going to be screwed a little bit on time, unless I want to make every other single person late for the day, which frankly isn't fair.

How exactly is it that your physician--and I'm not kidding, this is a half hour of any primary care physician's day (on an EASY day)--is supposed to explain the intricacies of sulfonylureas and TZD treatment and why it is that I think we need to add insulin but dagnabbit I'm a little afraid of the weight gain; and look, I think we're going to have to bag the thiazide diuretic but I'm a little nervous about a LOOP with that old sodium, so here's why we need to do a 24 hour urine collection and what the heck is a creatinine anyway? How can I do that in 10 minutes when the patient doesn't even know what a pancreas is, let alone where it is?

Sure, it would be great for me to have an hour to spend with every patient, but look at your paycheck. How much already comes out for health insurance and Medicare? And how much more might you be making if your employer didn't have to pay such high health care premiums? How much more do you want to pay?

Living is the best revenge

From a vegetarian cancer survivor, via the LA Times:

Somewhere along the way in our News You Can Use culture, good health has taken on the patina of virtue. Like good grades and job promotion, health is seen as bestowed upon those who work for it. There's no excuse for not doing everything you can, not with all the lists of necessary practices in popular magazines, not with all the attention to disease prevention.

The flip side of this is the judgment passed on those who get sick. They must have done something wrong, their diet must be flawed or they are overweight or drink too much or don't drink enough. Weight is the easiest handle for bestowing blame because we can see it and because we have been taught to associate all manner of poor habits with excess weight. But there are other handles. Somebody, somewhere is drinking a latte with whole milk rather than nonfat and someone else is driving three blocks instead of walking.

Regardless of what you do, life is a terminal condition. You play the odds; I play the odds. You play the hand you're dealt, whether you like it or not. But any way you play it--fast, slow, indolent, active, bouncy, or slugging, you're going to die. Maybe you'll get sick first; maybe you won't. Maybe I will, maybe I won't. I sure won't be having skim milk in my quadruple double latte tomorrow. Don't judge me for my lack of skim milk and don't hate me because I'm beautiful.

On the subject of quadruple double iced lattes, let me note that wow, that quadruple double topped off with Diet Coke and albuterol (I was a wheezer today) kept me moving swiftly until late in the afternoon.

Lovely

From the newly reborn Examining Room of Doctor Charles:

It’s enough to make you cry, every day. There’s an epic poem within each trivial office visit.

But sometimes, even if it’s just a single breath, I allow myself a silent, meditative, and empathetic pause. Great literature, tragedy, and the very bones of our pitifully glorious existence are forever one question, and one perilously considered answer, away.

From the Examining Room of Dr. Latte:

Despite the shit of insurance companies and the unbearable burden of getting paid by Medicare, despite the FMLA and disability forms, despite the call, the weekends, the worry, the gut-wrenching terror and overwhelming grief, the exhaustion, the student loans, and the dead and putrefacting rabbit-filled brains of politicians doing their worst, as long as it's still magic for me to be invited into a life and offered a chance to help, oh, and get paid, I'm there. It helps if there's a cold drink.

Oh, Gawd

$170K per family physician? Seems a tad on the high side for the average, but HUH? Less than a nurse anesthetist? Sure, there's some skilled labor involved there, but geesh. It's shift work without call under supervision.

Yet another reason why it's going to be impossible to find a primary care doctor soon. They're all leaving to go to nursing school to become anesthetists.

The Best- and Worst-Paying Jobs for Doctors

via Forbes. Depressing. I still haven't paid off my student loans.

Healthcare for dummies: International Edition

Image via Wikipedia

Interesting piece today from the McClatchy group of newspapers, by a reporter named Scott Canon, about health care and government involvement around the world. Not preachy, not ideologic, not bogged down in detail, but a nice summary I think, of how other industrialized nations deal with the burden of taking care of their population.

Few points of interest:

1. Everybody rations. Including us. Don't believe any politicians, insurance execs, or anybody else who tells you differently. Rationing and wait-times don't necessarily mean worse outcomes. But remember, they're already a fact in the United States.
2. When fretting over government involvement in health care, remember that government has been involved in education forever, and it seems to work for the most part. Nobody seems to be all bent out of shape about it. If you can read this, in fact, thank the free public education that the government of the US of A ensured you had access to. We might not all get a Harvard education, but it is possible to learn to read almost anywhere in the country.
3. The French have not only a health care system that isn't completely terrible, but they also have great food. (The food part wasn't in the article, but any time I read something about the French I have to run for a cookbook because my mouth waters at the thought of some kind of bistro.)
4. Even if you're not paying for health care at the point of delivery it isn't going to be free, nor should it be. I'm firmly of the mind that access to basic preventative and catastrophic care is a right, as well as a practical necessity. What isn't a right? To take a trip to the ER for free for puke times one because you can. Free benadryl. Cosmetic surgery. But what would be wrong with offering those things in a kind of cafeteria plan?
   

Clearly I should not be invovled in this reform. I'm not a big enough thinker. I just take care of sick people. Anyhoo, read for yourself:

World of Remedies

via The Columbus Dispatch

Surprise! Former Cigna exec says insurance companies don't care about you

Not a surprise, and if you were surprised, go back to school. Businesses are for-profit entities. So are physicians, for that matter, and even non-profit hospitals have to make a buck to keep the lights on. Insurance companies dump sick people; raise premiums to impossible levels for small businesses who turn in a lotta claims, and don't generally know the individual names of their subscribers. Investors don't want to lose money, in fact, they have the AUDACITY to want to make money. Not a surprise.

What is a little more disturbing in this video (transcript linked below) is that our elected officials open their mouths and insurance lobbyists come out, much like when I'm yelling at my kids and I hear my mother's voice issuing forth from my lips. I guess I'm not disturbed as much as more pickled in disgust. This nice gentleman shows up on Bill Moyers no doubt after receiving a generous retirement package before the economy tanked and blows the whistle from the comfort and safety of his vacation home. It's pretty easy to quote Robert Kennedy quoting John F Kennedy quoting Dante--"The hottest places in hell are reserved for those who, in times of moral crisis, maintain a neutrality"--from a nice cell phone in your Mercedes.

Am I surprised that moronic Congressional idiots and their lackeys--of both parties--lack the intellectual brainpower to come up with original thoughts of their own regarding health care? I shouldn't be.

Bill Moyers Journal, Wendell Potter

Thanks to my Rowing Reader for bringing this to my attention....

"So I wait."

Thanks to the NYTimes for this. My dear Little Latte and Macchiato, I would wait forever. Amen.

Don't set the straw man's tooth on fire

Image via Wikipedia

Check it out:

When flame meets straw (man, that is)

This whole sordid, nasty, doctor vs. doctor vs. hospital vs. nursing home vs. drug company vs. drug store vs. HCFA vs. ultimately patient and taxpayer is seriously making me ill. ILL! So ill, in fact that I chipped a tooth yesterday. On a hamburger. A really, really good one, but ultimately it's a $700 hamburger, 'cause that's what my new crown is going to cost.

So I'm at the dentist getting an emergency temporary crown. As this guy, who really was lovely and did a stunning job and got me in at the last minute on his late night, has his hands in my mouth up to his elbows (because, of course, I had to crack a molar) with whirring dremels and gum retractors and all manner of things that were just slightly less evil than gynecologic tools (thank you, lidocaine), he's lecturing me about how doctors screwed themselves. "Never should have accepted insurance." Dentists, he noted, have to accept some insurance for preventative stuff. Everything else, though, people have to pay a fair share for. And it works just fine.

Well, for who? For dentists. But I didn't suggest that because I at the time I had sharp objects in my mouth and I couldn't really move my tongue and I had a death trip on the chair and who wants to offend a guy who's got a dremel in your molar?

But I'm a physician; my husband a lawyer. We have great benefits, including dental, and max what we can every year to a health care FSA. I had to lay out $700 cash yesterday for the work, and believe me, I happily did. I was treated like a queen, expediently and competently. It's not what I WANTED to do with $700, but it's not a stretch.

But I've treated one too many nasty abscessed gum/tooth/jaw blechy pus-filled, foul-breathed infections in patients who don't have dental insurance. The dental insurance thing sure didn't work for them. Many of them don't don't have medical insurance, either. Hell, at last count TEN PERCENT of the country doesn't even have a job. The system doesn't work so well for those poeple, I'm guessing. I've had jobs in my life in which I worked just as hard as I do now--harder, in fact--day in and day out. Not fast food jobs. White collar prissy jobs which included free downtown parking. But if I'd chipped a tooth with one of those jobs I'd be sucking it up and waiting for the abscess to happen while my nubbin shredded my tongue. I didn't have a lot of spare change, and I didn't even have kids then. And I drove a used car.

I remember, in fact, once when my first husband had an abscessed tooth. We didn't have any insurance, although we both were working at least three jobs between us. This was TWENTY YEARS ago nearly for crying out loud. We went to an Urgent Care and blanched when they demanded a $100 payment up front. He received a prescription for Cipro. When we got to the pharmacy, the Rx was $120. One hundred and twenty dollars. I cried. I handed the pharmacist my Visa. Throw it on the pile. I didn't have the money. It was months before we'd saved enough money for the poor guy to pay a dentist to PULL the tooth. We couldn't even dream of restorative work.

It's not better now for most of you, it's worse. It's fine for me. I can afford my lovely new crown, although I'm going to have to postpone my iPhone purchase, so I'm going to call it the iCrown. Poor iMe.

Single-payer? Multi-payer with a government option? Maybe. Free to all? No way. That crap doesn't work. It means patients taking the squad to the hospital for gas pains, and if you think I'm kidding, I'm not. It means taxpayers shelling out for generic Tylenol and that definitely isn't okay with me. If you can afford a better cellphone than me you just can buy your own Tylenol, so don't ask me for a prescription. Yes, I'm talking to you Medicaid patient.

But this bullshit has got to stop. I just wanna see sick people, and sick people just wanna be seen. BULLSHIT, piles and piles of papers and laws and regulations and shit, shit, shit and greedy pig-headed buttweasels have gotten in my way. And yours.

The iEnd.

BANG: Evidence-based medicine meets ingenious children

Hats off to the kids. They offered a creative solution to a problem, which elegantly demonstrated the problem with working on #$*)W@$(* humans. It's maddening, it's endearing, it's uniquely human. It makes me laugh. I kind of imagine Spanky and the Gang clamping on pedometers to their dogs, then throwing rocks in a creek all day. But that dates me in a very Huck Finn kinda way.

Anyhoo, regardless of what the evidence shows in the lab or in the study, when there's a lazy solution to a problem, a human will often take it. The diabetic standing front of the bakery case may well get a doughnut right after swearing on a stack of bibles in your office never to let a simple carb pass their lips again. "Of course I'll stop smoking, get my mammogram, exercise EVERY DAY and eat five servings of fruits and vegetables, Doc. Right after I work 10 hours in a job I might lose any day, make dinner for my kids, do two loads of laundry, get to the grocery store, walk the dog, and pay the bills. And fold the clothes. And put them away. And empty the dishwasher, and get the trash ready for the morning, when I have to stop at my Mom's to pick up her check to put in the bank for her and then at the post office, then get to work after I drop the kids off at school.

Kids Fool Obesity Researchers, Put Pedometers on Dogs

via WSJ Health

Why can't I get an appointment with my doctor?

From Doc Gurley, my hero, a great post about why getting an appointment with your doctor is so tough. It's even tougher if I'm your doctor, because, of course, my panel is now zero and my practice closed. Anyhoo, back to the topic at hand. Dr. Kevin summarized Doc Gurley:

Most patients complain about the time they have to wait to see a physician.

Not only the time between an appointment and the office visit, but once there, the time it takes to actually see someone.

After internist Jan Gurley breaks down the numbers, it’s easy to see why. Primary care doctors, on average, have patient panels averaging 2,500 patients or so. Assuming full-time working doctor who only takes the 10 federal holidays off per year, “[patients] ‘own’ only (50 weeks X 40 hours, minus 10 X 8 hours, minus 50 weeks X 8 hours; divided by 2500) 36 minutes a year of [their] doctor’s time.”

That’s assuming a situation of no delays, no complications, and an efficient practice - traits that are not common in many offices.

And after citing a JAMA study concluding it takes primary care physicians about 18 hours a day to provide the spectrum of recommended preventive care tests and counseling to a typical patient, it’s no wonder that providing good health care is, as Dr. Gurley states, “physically impossible.”

Read Doc Gurley's article if you feel like being depressed. I listen to the news every morning about health care reform and how pissed off cardiologists are and how hospitals are all going to go bankrupt and pharmaceutical companies better be prepared to cut BILLIONS and RVU this and Medicaid that and I am rather glad to be out of the drama for a while.

Except that I miss my patients. And staff.

For those of you studying for boards....

And you know who you are, a couple of readable reviews on some perpetually confusing (at least to me) topics. Thanks to Dr. Polaneczky at TBTAM for completely terrifying me and causing me nearly to spontaneously combust when I caught a glimpse of the adrenal steroid pathway in her blog today. I am still considering praying for death, however, she saved my life with a lucid review of the details, and a handy link to the NYTimes article this week on the subject of:

Congenital Adrenal Hyperplasia

Whoppee! Dr. P, I owe you one (and my life) on July 24th if I answer a question on the recert boards correctly thanks to you.

Clinical Correlations also recently did a nice review of Conn's Syndrome. The author included a lot of historical detail which is great because it's a lot more interesting to me than Conn's Syndrome details. Sadly, I have a feeling that a question on the boards, or even a real live patient with the problem won't be as interested in Dr. Jerome Conn's work in the 50s and the military's interest in the sweating people of the South Pacific. Alas.

Read all about it for yourself:

Grand Rounds: Primary Aldosteronism, Beyond Conn's Syndrome.

reBlog from IcedLatte: Three Squares

I found this fascinating quote today (fascinating in that I wrote it myself):

My friend Dragon had a party on Saturday night. It was chic and involved roasted pig, so how could it be anything but fab? I did NOT know what to make and thus was forced to procrastinate all day, waiting for inspiration to strike me. I was drawn to the watermelon (seedless) which had been sitting on my counter for a week. I asked the Cookery Encyclopedia of Google for watermelon salad recipes and came across a quite a few. Sadly, I lacked ingredients for the interesting ones. I also lacked time, thanks to stalling most of the day.IcedLatte, Three Squares, Jul 2009

Read all about my very own recipe at Three Squares.

If you see one of these run screaming from the room

From a dear friend and reader:

2o Scary Old School Surgical Tools

I appreciate that the amputation saw had some pretty little filigree detail. I also appreciate, as the caption notes, that said decorative detail would be a lovely little home for some nah-sty little bacteria, which would absolutely LOVE to take up residence in your flesh. Be sure not to miss:

• The practical arrow remover
• Hemorrhoid forceps (OUCH)
• Pretty and terrifying vaginal speculum
• Lithotome (more than a passing resemblance to Brancusi's Bird in Space
• My favorite, the tobacco smoke enema

via Vital Signs

Can't resist a good photo

From the NYTimes:

Showcare, Life Behind Glass

Fascinating. I loved the Hong Kong photos, too. If you have a chance take a look.

First Day via Dr. Sanjay Gupta

Via of Clinical Cases and Images (how DOES Dr. Dimov find the time), this rather sweet video about a first day resident and African American graduates from medical school.



Let me say this, which I can because it's my blog and I can say anything I want, so there. This young physician exudes a lot more confidence on her first day than I did. Wow. As I watched the story and worried about health care in rural areas and the inner city, and then worried about health care for everybody, then worried about health care for my old patients, then worried about my old patients, then flashed back to my first night of call, coincidentally also OB, in which I did 65,943 deliveries before 2am and had at least 954 ER hits and gave more terbutaline to more women than ever before in history, and painted lactated ringers all over town, it all comes down to the baby. Right at the end of the video, awash in worry and fretful memory, there was the baby.

I delivered, in fact, five babies that first night of call. There are five little people in the world--not so little anymore, in fact--who saw me first. My panicky hands held their slippery, wriggly little bodies first. As residency went on, I was occasionally the last person somebody (maybe) saw or heard as they died (poor them). I'm sure my fat head is indelibly imprinted on some patients' and families' brains as the person who gave good or terrible news. They don't remember my name, but they remember my unplucked eyebrows, or shoes, or nasal voice, or crooked fingers, or the way I stooped while I stood or hunched while I sat.

I don't sit beside or partake in much of that drama anymore, but I still love ushering people into and out of my office, with or without prescriptions, physical therapy orders, pats on the back, a good joke, advice, instructions, anticipatory guidance or anything else which might help. No matter the swirling chaos and barbarians at the gate of healthcare reform, for me it always comes back to the patient and the magic special space between the first breath and the last quiet heart beat. Despite the worry, the heartache, the upheaval, and the relentless needs of the sick, it's more precious to me now than it was, ever.

Good luck to you my new colleagues. Enjoy the ride. There's nothing like it and nobody but your fellow physicians will completely understand that. And not all of them will remember it. Take it away from me, US Government, and I'm walking.

But happy 4th of July from me, IcedLatte.

Ah, the new medical year

July 1st came and went, and most of you didn't feel the ground under your feet move. New interns sure did. New second year residents sure did. It's quite an adjustment, let me tell you. A month ago, when still a medical student, you were the lowest of the low in the a pile of medical dung. Suddenly, a month older but a month not at all smarter, you find yourself with a pager and a nurse at the end of a line waiting impatiently for you to mine your intellect and tell her what to do about a patient who is crashing. Or who has insomnia. Or who is running naked down the hall shrieking. Or you have to show up to deliver a baby, something you haven't done for over a year and never alone. You have to go to a surgery and appear to be somewhat competent even though you are not. That first night of call? It will haunt me until the day I die, and I'm not kidding. It was the most terrifying, exasperating, exhilarating, challenging thing I've ever done. Edwin Leap has some advice, and it's good. I wish I'd thought of it.

1) It’s going to be hard. Deal with it. The less you whine, the more you will be loved and trusted. Learn to be strong, learn to power through your fatigue (ed: Coffee and Diet Coke and onion rings and showers are divine). And remember that it often takes more energy to avoid work than to just do it (ed: Amen, sista!).

2) Do the right thing. Ethically, professionally, morally. Be the one everyone can count on to do the right thing; however hard it may be. (ed: And don't wear a t-shirt every day telling everybody what a good job you did.)

3) Humans, to paraphrase Blaise Pascal, are glorious and wretched. Capable of nearly angelic goodness and demonic evil, they will both thrill and disappoint you. Be neither too judgmental nor too naive. And remember that you, dear ones, are human as well. (ed: You can always find something in anybody to like and admire, even if it's a clever place in which to hide a rock of crack. That said, there will be patients who will make you want to claw your eyeballs out. Figure out what makes them have such fiendish power over you, then go get a Dove Bar.)

I survived many a night of godawful call by carrying around a giant Diet Coke with tinkling ice cubes. When I "needed a moment" I'd close my eyes and tinkle the ice and imagine I was wandering through the hospital with a cocktail. I also always made a point, whenever it was possible, of watching the sun come up from the 6th or the 8th floor patient lounge. The hospital was downtown, and watching a new day start, watching people below and in the distance turn on their lights, below get their papers, drive to work reminded me that even on the worst night of call the sun always comes up. You can't stop time.

If the patient were the president, would he get it?

I do apologize for my recent dearth of posts. In my defense, I can only say that I've purchased at least six pairs of shoes THIS WEEK for my new job. Beat up jeans and flip flops don't cut it in academia. At first I was irritated and thought that flip flop-free feet would be a deal-breaker, but then I realized that I had an unprecedented opportunity to shop. To go with the new shoes of course, what could I do? Shop for clothes. Then, don't you know, it was my birthday recently and my darn husband bought me a day at Ikea (a cheap day, but a great day nevertheless).

Those damn upcoming recertification boards have kept me from perusing the popular lit-er-ah-ture as well. I have, though, for my dear readers, carved out a little time today for a few posts.

Speaking of posts, I hadn't checked out the Washington Post for a while, but thanks to Dr. Wes, was directed there for a column recently by Michael Kinsley about rationing health care. Some gems:

We consider the best possible health care to be a right. Few would find it acceptable for a poor person to die of a medically curable disease for lack of money. Even fewer would find it acceptable that they themselves should die because the system won't spend the money to cure them. This is all in theory, of course. In practice, people die all the time because some effective treatment is too expensive.

Or because they live under a bridge. Or staved. We ration housing and food without a whole lotta squeamishness, eh? Health care is rationed and has been for some time. When you listen to politicians screaming to you about the perils of rationing, regardless of their party, stick a fork in them. They're done. It's rationed. Utterly.

Less care doesn't necessarily mean worse care. The administration is investing great hopes (and $1.1 billion of stimulus money) in "comparative effectiveness research." Because we don't collect and compare in any systematic way the vast piles of data we have about individual patients and their treatment, we know astonishingly little about which treatments work and which are a waste of money. The administration is touting the figure of 30 percent of all health-care costs as spending that may accomplish nothing.

I suspect that what a billion-plus dollars' worth of research will find is that perhaps 30 percent of what we spend on health care is almost entirely worthless, or just barely better than a much cheaper alternative. Or it might be better and no one knows for sure. Denying someone these treatments or tests is rationing.

I think if I asked a whole bunch of physicians about comparative effectiveness they'd roll their eyes and run and hide just in case it was attached to pay for performance. Is it worth spending a billion plus to find out what Monsieur Kinsley is almost certainly correct about? That 30% of what we spend on health care is crap? We could vaccinate a lotta kids for a billion plus. And that's a fer shur, 100% effective intervention.

Similarly, when fear of malpractice lawsuits leads doctors to practice "defensive medicine" -- a legitimate complaint about current arrangements -- it doesn't mean that they order worthless tests. It means they order tests with only a very long-shot chance of finding something wrong.

Here is a handy-dandy way to determine whether the failure to order some exam or treatment constitutes rationing: If the patient were the president, would he get it? If he'd get it and you wouldn't, it's rationing.

Oh yeah, baby. I order test sometimes just so the patient or their lawyer doesn't crawl up my you-know-what. Is it worthless? Sometimes. Not all the time. I've scanned many a gallbladder and found a weird mass, occasionally cancer. That's a life saved for the sake of a soft gallbladder call. Now, if a private insurer is paying for the soft-call gallbladder ultrasound do I feel differently about it than if MY tax dollars are paying? If that person can work another 20 years because I caught a renal mass which otherwise would have killed said patient in 8? But what if curing the cancer cost more than the taxes the person paid in 20 years to Medicare? Who can comparative effectiveness research that for me? Do I order the test, knowing that my tax dollars (and yours) are going to help pay for the scan, knowing that there is absolutely positively no way in HELL that this patient could EVER earn enough to pay back the money that their goverment-provided insurance shelled out to cure them (or, God forbid, not) of the cancer I might find?

Whatever. Frankly I'm disgusted and fatigued by the whole thing. I already hear specialists moaning about paycuts. I'm having a little trouble working up sympathy, since I just lost a job and 2000 patients lost their physician so that the hospital system I worked for could hire more cardiologists. Turns out it takes about 3 primary care doctors to hire each of those cardiologists, so my hospital system got ride of 20 primary care doctors (and counting, times say, 2000-25000 patients each). These specialists (who are just following more secure employment) are not to take care of more patients, they're going to to take less care than I did of of fewer patients who need better-paying procedures. Sorry about your depression and your gout and your osteoporosis....But we have a shiney new cardiolyte for you to take out on a spin!

But it's math. The hospital system has to pay the bills and keep some lights on. They think cardiologists will pay the bills. Maybe. We'll see. In any event, I survived.