Apologies are in order

Apologies are in order. We are cooking up a pot full of crow for people to eat.

We pray that all of the accusation, insinuation, and conceit that we have had to endure over the past two years is finally over. Everything that we have been led to believe is false. What we do know:

1) There was no collusion between Trump and the Russians.

2) Clinton illegally used an email server to try to avoid federal oversight of the Clinton Foundation, which was making her rich at the expense of the American people.

3) Clinton and her campaign invented a series of false scandals called the “dossier”, implicating Donald Trump.

4) Washington insiders including John Brennan, James Clapper, and James Comey covered up for Hillary Clinton and attempted to use the above “dossier” to remove a sitting president from power. This constitutes an attempted coup. And to note more recent garbage in the news, John McCain was in on this as well.

5) The only “collusion” was between the Washington insiders and the Clintons to cover up their crimes and try to pull one over on the public.

So it is now time for the people to reclaim their country from the media and the Washington elite that have taken control of their lives.

Stop illegal immigration.

As a small ‘l’ libertarian or “classical liberal”, I am all for open borders. But only when there is fair play among countries can this occur. As things stand now, our open borders policy is killing us. We cannot be the life support for the rest of the planet. Only once wages are reasonable, workplace standards are up to par, and expectations of the contribution of each individual are delineated, may a country expect to have an open border with us.

Stop “free” trade.

As a libertarian I believe that there should be no barriers to trade. But I also know that different countries and peoples hold different values from Americans. It is not a fair system to drop trade barriers in order to exploit a worker in China. Sure, it may improve their standard of life, but only as judged against the American way of living. It is not up to us to fix the entire world. It is not up to us to solve the problems of China and India. Do not listen to the “globalists”. We have enough problems here at home to solve before we try to solve the problems of other countries.

We need to suck it up and accept that not everything in life comes cheaply. We need to work to create the things that we want in our lives. What free trade has done is to undermine the fair worker policies that we have established over the past one hundred years. All of the laws for the safety and the minimum wage of the worker that we have established are thrown into the trash by allowing free trade with countries who do not share our values. What is more important to you: a bigger TV, or a decent life for your countrymen?

Stop interventionist wars.

We need to stop trying to be everyone else’s policeman. Stop trying to change the policies of countries halfway around the world. Yes, we should be a beacon, a shining light to the rest of the world. That does not mean that we need to go mess in others affairs.

If we can do these things, we may be able to restore what this country was built upon.

On snowflakes:

A problem in our society is that people are sensitive, but they are not allowed to admit that they are sensitive for fear of being called “weak”. People have feelings. Feelings get hurt. People feel embarrassed: Sometimes there is a good reason for the embarrassment, and sometimes not.

Each individual needs to decide how much of their private life they want to expose to others. Some people are ‘open books’ while others are very hard to get to know.

The ‘rugged individualist‘ archetype is a helpful example for how people should live their lives. This is the hard working person who just wants to go about their business and not be bothered. You can attack that person and put hardship on that person, and they will just continue to bear it out – to a point. And when that point comes, and the person makes a stand, you had better watch out. This has been the foundation of many books and movies, but more deeply this embodies the American spirit.

This rugged individual is not racist, nor misogynist. This rugged individual appreciates all people for who they are. This rugged individual speaks the truth, and sometimes the truth hurts. And to those who say that speaking a hurtful truth is ‘insensitive’ – they are the ‘snowflakes‘.

I say to all snowflakes: Get over yourself. Yes, you are a human being and I will treat you politely, but if I step on your toes accidentally while trying to do something, don’t start calling me names like ‘racist’.

A major problem with our society is that we have become fat and happy. Way too many people live too far away from the harsh realities of life and death. For example, if I ask: Where does your food come from? If you say the grocery store, you are a step away from reality.

If society were to break down completely tomorrow and you could not get water from the tap, food from the store, or electricity from the substation, what would you do? What is important at that stage? People have forgotten what true need is like. People have forgotten what war is like. Life and death, hanging by a thread. People being shot for no reason.

Be grateful for what you have. We have things in abundance in our society. We should stop bickering and get along.

Chill

I am currently embroiled in a fight with a company and it made me think about the fact that we used to discuss business across a table. These days people make decisions over the phone without looking their opponent in the eyes. Negotiations used to be done in person where you could audibly and visually see the other human being that you were dealing with. Now negotiations are done via Twitter or text message.  

I, personally, believe that all of this social media nonsense is a poor replacement for real experience. Please, people, go enjoy the beach, and do not just use it as scenery for your social media post.

Relax. It is OK. Your phone can wait.

Impasse

Here we stand with the (non-essential) government closed and the Democrats not willing to budge on the border wall. An impasse. What to do? And as I have been writing this even more absurdities have come from Washington. Now the Grand Dame has disinvited the President from delivering the State of the Union address.

Let us for a second stand back and see what has brought us to this fine state. Illegal immigration has been an issue throughout my lifetime and neither Democrats or Republicans have been able to solve the problem. Why? Because they have vested interests in the status quo.

Democrats see new immigrants as potential voters and have been quick to provide a lot of benefits, or ‘handouts’. What benefits? First of all, we provide safety – it is a nasty world out there. Then we provide school for the kids. We provide welfare for people not working. This is all done in the name of compassion, and that is all well and good, but we cannot provide this for the entire world.

Republicans see donors who use the illegals for cheap labor. They get rich running companies that use workers unfairly. When you are an illegal alien you do not have a voice to complain about poor working conditions or low pay.

So the problem goes on and on. It is not as simple as people walking across a border because people are being used and abused. People are raped and abused and die in this insane system we have concocted and supported for years, but the reality of that world remains light years away from the cushy seats in fancy houses in Washington.

How can we fix it? A wall is a great start. We need to close the door to further illegal immigration. Legal immigration is great and provides us the people we need to make a better country, but illegal immigration needs to be stopped.

Democrats say that we should open the government first, and then we can negotiate. Fool me once, shame on you. Fool me twice, shame on me. What evidence can the democrats provide to show that they will actually negotiate this time? Remember, this problem has been going on for twenty years or more.

And that brings us to a bigger question, which is, why should all of these non-essential things be run by government anyway? The key is right there: they are non-essential. So yes, it may be nice to have things provided to you, but those are niceties which may be better provided to you by independent companies. There is no reason that the government should have taken over most of these niceties. When the government takes over something it stops developing, it becomes bland, and you lose options. Now I will admit that there are good people who work in government and you may have a good experience once in a while, but for the most part state operations are lacking.

Why is this? Simple nature. Survival of the fittest. Government goes against survival of the fittest. I will explain. People create companies to make money by providing a product or service for the community. These companies compete for the public’s money by providing value. If a company does not provide any value, the company will not succeed and will die. The companies with the best products and services grow and thrive.  The companies, and the people that run them, are motivated by making money. This is capitalism and survival of the fittest.

Now compare this to government. Companies come and go but the government just stays. What is the motivator to get government to do anything? There is none. The government couldn’t care less about what consumers want.

Most of the fuss about the government shutdown is not even about the supposed services that these bureaucracies provide. Most of the kerfuffle is because the government workers are not getting their paychecks. And when they don’t get their paychecks they can’t go out to eat and shop and it makes the rest of the economy have problems (mainly in the Washington, DC area). Hey, I feel for these people, I really do: I know what it is like trying to balance a budget when you have no income. But compared to what is at stake for the entire nation these are small potatoes. And just how sorry should we feel for these government workers who:

  1. have Cadillac benefit plans with a pension (who else gets pensions anymore?)
  2. have almost unlimited job security
  3. will end up getting their pay in the end anyway

Maybe some of them should try getting jobs in the private sector and see how the real world works.

So how do we fix all of this? What is the solution? We need to get back to fundamentals. We need to recognize that government is not the solution to every problem. We should start to dismantle some of the more useless parts of our bureaucracy and get back to basics.

And to all the Washington insiders, the ‘establishment’, the ‘swamp’, the ‘deep state’: Know that we are watching you, and we are getting more and more tired of your sorry excuses for getting nothing done. One of these days we may come with our pitchforks. So just do it. Solve the problem. Give him the damn wall and take the DACA deal in trade. It’s not that hard.

Unintended Consequenses

Unintended consequenses are inevitable when making global decisions in a system as complex as medical care. Unfortunately doctors have ceded too much ground to the bureaucrats and it may be too late to save the system without a complete collapse. Over the past two decades the number of doctors in this country has grown with the population. The number of medical administrators, however, has exploded, and these people now consume a large portion of the health care dollar. The administrators and non-practicing physicians spend a lot of time NOT caring for patients but telling the rest of us what we are supposed to be doing with our time and talents. We now have a number of very entrenched special interests that dominate medicine (i.e. Pharma, device/medical equipment companies, hospital corporations, and the government) with little to no input from physicians and with little thought to the consequences for individual patients.

I could give hundreds of examples of the insanity of the current system, but in the interest of time I will give one: a single example of the mind-numbingly idiotic machinations of “the system” is the fact that inhalers are quite expensive for my patients to the point that people are going without medicine and dying. Why? Global warming!

What? you ask? Now we can argue all day about the amount of climate change going on and how much humans have to do with it, but I doubt that anyone would argue that asthma and COPD sufferers are big contributors to climate change. But that does not matter in today’s insanity. Because of “climate change” big Pharma can lobby to make the propellant gases used in inhalers illegal, so that the reformulations – now required by law – can allow them to extend patents for another decade or so. So the old MDIs are out. Now people have to use these “respi-click” inhalers which are difficult for elderly patients with arthritis. And Pharma gets to charge hundreds of dollars for these new inhalers for medicines that should be dirt cheap.

People get hurt. And I would be willing to bet that if you calculated the carbon effects of creating the new manufacturing plants for the new inhalers the overall balance in the carbon calculations would be a wash, if you even believe the carbon dioxide hypothesis of climate change to begin with.

This is just one small insanity in the sea of insanities that is modern medicine. It is no wonder that good people are leaving the occupation in droves. Why would anyone want to be a doctor today? The prestige is gone. The money is gone. The work is shit and we have to listen to the ‘C’ students who are now hospital administrators telling us what to do. Bad EHRs are just adding insult to injury.

I did see a sign posted in one doctor’s office that I think should be a standard sign posted in all doctor’s offices. “Don’t mistake your Google search for my medical degree”

Liberty Under (Friendly?) Fire

Filkins-Do-Not-Resist

After a recent assault on a New Jersey beach, it is becoming even more clear that we have too many police in this country. A well-known fact is that we lock up more people in the United States than any other country, but the reasons why have not been entirely clear. One of the main reasons has been the failed war on drugs, a nearly fifty year debacle that has led to a near police state and the jailing of countless numbers of people whose only crime has been to seek an escape from the tedium of daily life.

Under multiple administrations, local police in this country have become increasingly militarized, using surplus military equipment donated or provided with generous subsidies to local police by the Department of Defense. This has led to deadly SWAT team raids, often on innocent bystanders, leading to increased tensions between the populace and the police, particularly in minority communities, which are disproportionally targeted by these police raids.

Misunderstanding of the origins of this problem has led many people to believe that the motivation behind these police activities is racism, but as can be seen by the assault on the beach above, white people are caught up by these Gestapo tactics as well. Assault by police on white victims does not play into the national media’s narrative of widespread racism and so often goes ignored. The alleged victimhood of minorities in this country is also one of the few remaining sources of power for the Democratic party, which is otherwise bereft of ideas, as the Dems must keep large portions of the population dependent on government in order to stay in office. The combined propaganda power of the mainstream media and Democrats keeps nearly half of the population of this country entranced by outdated and misguided ideas.

This is not a recent problem, although it has certainly worsened over the past fifty years. I recently watched the movie Vanishing Point, in which the protagonist, a car delivery man named Kowalski, is targeted by police for attempting to run a car from Colorado to California in record time. His only crime at the start of the film is speeding, which given his history as a race car driver was not likely endangering anyone. In general, speeding is a victimless crime, only becoming dangerous when combined with distraction for the driver. Unfortunately, speeding is something that is quite easy for police to measure and prove in court, in contrast to driver distraction due to cell phones, eating, or putting on makeup. Anyone who spends any significant time driving will know that driver distraction is much more dangerous on our roads than speeding, yet it largely goes unpoliced and unpunished because doing so is challenging, and our police generally do not like challenges, only going after ‘low-hanging fruit’.

So, this goes back to my hypothesis at the start of this essay, that we have too many police. We are in a situation, and have been for decades, where there are too many police, and for police departments to fund their activities they must target and ticket large numbers of people who are generally minding their own business and not harming anyone. These activities are often defended by people (who do not know any better) under the auspices of the need to reduce crime. The fact that crime rates are at all-time lows goes ignored and underreported. The mainstream media needs stories of crime to generate ratings, and politicians need the illusion of crime to justify passing more and more laws. There are now so many federal laws that they are not countable.

Having an uncountable number of laws had led to a situation where almost anyone in this country has committed a crime at some time or another, usually unwittingly. This means that given enough time and resources, a prosecutor digging through any of our lives could probably find an infraction that could land us in jail. Most people do not have the resources needed to defend themselves when faced with this kind of power of a prosecutor and will take a plea, admitting guilt mainly to make the pressure go away. Western society used to recognize this as a tactic of run-away authoritarianism used in communist countries. The 1970 movie The Confession offers a frightening and thought provoking look at these tactics of the state and remains must-viewing for anyone who wants to understand what is happening in our society today.

The ongoing Russia-collusion probe by Robert Mueller is a good example of the dangers of unfettered prosecutorial power. An even more disturbing example from the UK is the recent arrest and secret prosecution of activist Stephen Yaxley-Lennon, aka Tommy Robinson, in England for attempting to report on an Islamic child molestation (grooming) trial. Not only was he arrested and thrown into prison for 13 months alongside Islamic criminals, almost ensuring his death in prison, but the judge issued a gag order against the media of any reporting about the imprisonment. Multiple web articles about the episode were promptly taken down by the subservient media, under fear that they would similarly be imprisoned for supposed “incitement”.

While I am not here to defend the tactics or opinions of Tommy Robinson, of whose history I am only recently becoming informed, there is a famous quote that I am reminded of: “I disapprove of what you say, but I will defend to the death your right to say it.” This quote has largely been attributed to Voltaire, although the origins appear much more recent. Regardless of the true origins of the quote, it has become a clear and succinct statement of the defense of liberty, one of the cornerstones of the French Enlightenment and of the founding of the United States.

What has happened to liberty in the West? It is a still-revered principle that is under assault by runaway police and prosecutors. These people have been given power by an uninformed populace with the misguided mandate to “reduce crime”. The assault on liberty is cheered on by the mainstream media, in search of ratings, and politicians, in pursuit of more power. Whether or not we will be able to preserve liberty, a cornerstone of Western democracies, is a problem that is increasingly coming into question. Only by becoming more informed and embracing the ideas of our founders will we be able to preserve their legacy for future generations.

STEMI or not STEMI?

I am currently stuck in a medical system that wants to treat all doctors and patients like widgets. The bureaucrats want to categorize all patients into neat boxes.
Tonight I had the perfect example. A patient arrived in the emergency room with an acute myocardial infarction. We categorize myocardial infarctions into ST elevation MIs and non-ST elevation MIs based on criteria seen on the ECG. This patient had borderline findings on her ECG and did not meet strict STEMI criteria. However, she had a good story, and an intelligent doctor who understands the underlying process can recognize that she is having an acute infarction. She should probably be treated like a STEMI, although she does not meet the criteria.
The system times us and grades us on our responses to a STEMI. Our reaction time and delivery of care goes into an algorithm that somehow defines the ‘quality’ of our care.
But this patient was not a clear STEMI. It was fuzzy. And dealing with patients is often fuzzy, due to problems with memory, compliance, etc…
So how do we change the system so that we can deliver the best care?
Asking these kind of system questions makes our administrators very uncomfortable. They want all of the patients to fit into boxes and for medical care to be delivered by flowchart. This is not reality.
It is important for people to recognize that patients are all individuals and medical care cannot be delivered by flowsheet. Good medical care takes thinking and accepting that patients often do not fit into neat categories. I do not have solutions as to how to best measure physician quality. A supreme court justice famously said of obscenity “I know it when I see it.” The same can be said of physician quality. Trying to measure quality through measures across a wide spectrum of patients is a fool’s game.

Self-interested in Liberty

For years it has rubbed a raw nerve whenever some pontificating pundit has put forth the idea that red-state individuals vote against their self-interests, but the discussion has been perverted so far that it took Frank Rich’s 4000+ word screed in New York magazine bashing readers about their heads with an almost mechanical redundancy to make me realize precisely where the problem lay. His extended article fired my imagination about what the true self-interests of the voters actually are, for I believe that Trump voters made a statement that does, per se, express their self-interest, but in so doing showed a preference for ideas which fly right over the pointy and outsized heads of the misguided unfortunates on the left.

Rich’s extended naval-gazing exercise regarding the arguments among many ‘progressives’ about the recent election was one of the most depressing pieces about America that I have read in a while (and that is time I will never get back). Not because of his premise, that working-class white Trump voters are all just bigoted rubes too dumb to realize that they need government to help them get ahead in life. No, the depressing part about this article was just how far the left has allowed the frame of the discussion to shift over the past few decades. Milquetoast conservatives of the Bushie brand have certainly contributed to this apocalyptic shift, but the distortion has largely been driven by ‘progressives’ and their toadies in the press, the government bureaucracy, and colleges and universities throughout this land.

So what is this seismic shift that has led to increased partisan divide and an inability of blue-staters to comprehend the thought processes of half of our population? It unfortunately has become part of the accepted narrative of our current politics that people who vote for less government are voting against their own self-interest.

Now this supposition may not seem remarkable to many of you, and in fact this new narrative may seem like just an ‘obvious’ statement – certainly to more ‘progressive’ readers. Many people may even believe that this is just a self-evident ‘fact’ and may even reject my hypothesis that this is a ‘new narrative’. But for those of us in the enlightened ‘traditional liberal’, i.e. conservative, camp this is a point that remains highly in doubt and one that should not be accepted without vigorous opposition.

Rich makes an argument that Trump’s working-class voters are so lost in their own red-state bubble that it may not even be worth the trouble for the Democratic party to try to reach out to them:

The most insistent message of right-wing media hasn’t changed since the Barry Goldwater era: Government is inherently worthless, if not evil, and those who preach government activism, i.e., liberals and Democrats, are subverting America. Facts on the ground...do nothing to counter this bias.

The ‘facts on the ground’ he refers to are the loss of working class jobs (which he attributes to greedy free market corporate robber barons) and the opioid epidemic (undoubtedly the fault of greedy pharmaceutical robber barons). He then goes on to say that:

The notion that they can be won over by some sort of new New Deal — “domestic programs that would benefit everyone (like national health insurance),” as Mark Lilla puts it — is wishful thinking.

But herein lies the fallacy of his thinking: believing that the only thing important in the lives of these people is the number in their bank account, health insurance, and the accumulation of material things around them. He makes the case that great unwashed hordes of hillbillies are really just out-of-work losers who don’t have enough brain cells to realize that the government has freed them from work (via NAFTA) and furnished them with financial aid and cheap imports from China, and that instead of being grateful and taking the blue pill for more of the same, they have opted for OxyContin induced bliss and early death. Only their always benevolent betters in government can save them from themselves.

By voting for Trump, however, they have cried out for a change in the national course. Glenn Reynolds’ article in USA Today makes a strong argument for one of the reasons why they have done so – the abject failure of so-called experts to solve our problems. The people want to be free of their overseers and provide for themselves. And one of the biggest barriers preventing these people from pulling themselves up has been the heavy hand of government, enshrining in regulation a Rube Goldberg apparatus of occupational licenses which purports to ensure competency of virtually every working person but instead offers a government provided protection racket to those lucky enough to already have a job while simultaneously reducing ‘expertise’ to the lowest common denominator.

Rich laments that Reagan’s dictum “The nine most terrifying words in the English language are: I’m from the government and I’m here to help” ‘remains gospel’ on the right, but it does so because for so many regular people it rings true. The media has repeatedly lambasted Trump and his supporters as anti-immigrant and used the words on the Statue of Liberty “Give me your tired, your poor, Your huddled masses…” to try to rebut his policy proposals but usually stops there without finishing out the phrase. It is instructive that to examine the rest of the poem, “The New Colossus” by Emma Lazarus, to see that Lady Liberty stands in contrast to the fallen Colossus of Rhodes, the “brazen giant of Greek fame, With conquering limbs astride from land to land”. She is not a monument to empire, or to what government has built. The “huddled masses” do not yearn for a handout from some self-titled ‘elite’, but yearn to breathe free: free from tyranny, free from the heavy hand of an unelected bureaucracy, free from self-righteous, patronizing, and smug pronouncements from urban pomposities who know nothing of the way of life or the values of half of their countrymen.

 

A Thought Experiment

A thought experiment: everything about you and everyone else is made public knowledge. Anyone can look in on your life and see everything you do. They can see what you eat, they see all of your interactions with other people, and they even see all of your sexual peccadilloes and when you masturbate. All affairs are revealed and all theft, fraud, and corruption free for anyone to sort through. The only things that you can hold secret are those things you keep in your own brain – never expressed to anyone or written down. Your diary is open.

 

What would you be ashamed about? What would you not want other people to know? This goes straight to what you consider to be right and wrong. This dives deep into religion and even sense of self.

 

This is essentially the state we find ourselves in with the most recent revelations of the extent of the spying ability of the United States government. And with the exponential advancements being made in technology – artificial intelligence, ubiquitous cameras and drones, aerial surveillance, facial recognition software, DNA storage capabilities – it is only a matter of time before all of our activities all of the time from birth to death will be captured in some huge database. Of course the spymasters will say that the only access to that database will be through judicious use of warrants. But if the policeman can get access to the database, certainly hackers will get access to the database, and sooner or later it is going to be fair game for everyone.

 

There are people who say ‘I have nothing to hide. Only people who have done something wrong need to worry.’

 

I fear the implications of this are much more dire. When employers can know all the employees’ medical results, when businesses can pull up the dirty laundry on the executives of their competitors, and when governments can monitor any activity that they may not approve of, where will we be? Forget about negotiations and market tactics – useless. Economies would crumble.

 

There are fundamental questions here. It all has to do with the power some people hold over other people. I wonder whether humans can live and work together without any personal privacy. I don’t know that I would want to live in that type of society. I don’t know that I will have any choice. This may solve the question of why we have not been contacted by other advanced civilizations. This may be why civilizations die.

Old school

A recent post at db’s medical rants addressed the question of whether or not the skills of history taking and physical exam have declined in recent years, and he asked the question ‘What does old school mean to you?

To me ‘old school’ means taking a good history and then performing a focused physical exam. So what exactly does this entail?

History:

Old school:

Questions are asked regarding the patients known medical conditions and the problem at hand. Relevant information is discussed, often but not always including some details about the patient’s occupation and family. If I am sewing up a laceration on someone’s leg from a chainsaw accident, I don’t need a family history, (but I might want to ask if any substances were involved). Treating a swimmer’s ear does not require much history at all, unless this is a recurrent problem or unusual presentation. On the other hand, a patient presenting with heart failure may need an hour’s worth of history, exploring other medical problems, current and past occupations, extensive family history, living conditions, and any history of substance abuse. The history adapts to the situation. I personally do not take notes or use a computer when taking a history – talking with the patient and looking them in the eyes

Modern reality:

In order to bill for the visit you need to make sure that you have checked enough items under the history of present illness, that the past medical history is documented, a social history is documented, a family history is documented, and an extensive review of systems is documented. Most of this is clerical data entry and is done by nurses or medical assistants. If you are very efficient you can click through the boxes to get a level 4 visit paid in a few minutes.

Physical exam:

Old school:

Hands on exam including (for me) listening to the heart and lungs of every patient, and then a focused exam regarding the issues that need to be addressed. In patients with diabetes or hypertension, a (gasp!) fundoscopic exam can be very useful. Looking at a patient’s hands can provide an encyclopedia’s worth of information. When patients complain of gout we actually have them take off their shoes and socks and (double gasp!) touch their feet.

Modern reality:

Too many doctors do not even examine the patient. They look at the electronic health record and click off the boxes. The entire physical exam section of the clinical note is boilerplate to fulfill billing rules. Patients tell me that they have seen doctors who did not examine them at all but stood by the door and diagnosed them based on what was in the computer. Some doctors seem to think that their patients are ‘icky’ and do not want to touch.

The problem of modern medicine

The problem today is a mentality that the history is all you need and then technology – lab tests and imaging – will make the diagnosis clear. This mentality has been driven by a number of forces. The most important force that drives everything in medicine is money. The way doctors are paid is insane. Take, for example, a challenging patient with a rare medical condition seen by two different doctors:

Doctor #1

Doctor #1 was the top of their class, well educated, sharp, engaged, and takes time to do a thorough history and physical exam on the patient. The doctor comes up with a presumptive diagnosis and sends a lab test to confirm or exclude the condition. After one hour, doctor #1 bills for 1 level 5 visit and a lab test. The insurance company refuses to authorize the lab test because it is for a rare condition and the bean-counter there has never heard of this test. They also question whether doctor #1 is billing too many level 5 visits. The patient then gets a huge bill from the lab company and makes an angry phone call to the doctor. The doctor’s practice goes broke and he burns out.

Doctor #2

Doctor #2 was at the bottom of their class and has no clue as to what could be wrong with the patient. He spends five minutes with the patient, orders 100 lab tests, and refers the patient to a specialist. He then goes on and treats eleven other patients that hour in the same way. After one hour, doctor #2 bills for twelve level 4 patient visits, 1200 lab tests, and laughs all the way to the bank.

 

Which doctor do you want? Doctor #2 may be just fine if you have pink-eye or a stubbed toe, but what if you have amyloidosis and need a heart transplant? Why does the system favor doctor #2 so much?

 

Old school

You must put hands on the patient. There is a tremendous amount of information that is gathered by simply listening to the heart and lungs. Patients often do not tell everything up front. You can take a history that you think was complete and all of a sudden you see a scar and ask about it. A patient will then spill out ‘Oh I had heart surgery as a kid’ or something similar. (it would have been helpful if they had mentioned it before)

Check-boxes and past medical history forms are not sufficient to obtain a medical history –they are only tools to get paid.

What ‘old school’ seems to mean is actually being a doctor. Taking time with patients, touching patients, and examining them is essential to medicine.

Some doctors think that it is OK to not learn about different heart murmurs – just get an echo. What a waste of resources! This is why medical care is so expensive. Yes, an echo can tell you more about the heart, but the way the medical system is now this requires time, money, and lots and lots of paperwork – er, computer data entry.

If we were paid a salary as doctors instead of fee-for-service everything would be much easier. Then we could use echo machines for diagnosis and not worry about what billing code we need to use and making sure that we have a complete study. If our payment system were different we would all be using mini echo devices just as we (well, at least some of us) use a stethoscope today.

This is why doctors switch to concierge practices. Unfortunately this is not an option for most specialists.