Friday, April 24, 2009

Doctor Autonomy

Just as a patient has autonomy (self-rule) for health decisions, a doctor has autonomy in practice decisions.

A doctor has autonomy to decide the mode and scope of his/her practice of medicine. Mode, in this context, refers to employment, location, associations, etc. Scope of practice is simply what services the doctor provides. Some conditions of practice are prescibed or regulated by national or local law (such as non-discrimination statutes), and some conditions and practices are prohibited, otherwise current U.S. law allows freedom for doctors to decide these things.

Employee or self-employed? If employed, by whom and under what conditions? Where?
Solo or group practice? Locum tenens? Staff model HMO? Government?
Doing which procedures? Under what conditions? For whom?
(Scope of practice enters into the mode of course, as a doctor needs to perform within the requirements of employment). 

When I chose solo, rural, self-employed practice I accepted certain conditions which came with that decision and are different from other modes of practice. For instance, I have more independence and flexibility to follow my own values, but more responsibility for the business side of practice with less security.  

My scope is based on my training, experience, preferences and belief system. It has changed with time, mostly I have reduced the procedures I perform after my skills atrophied since training (e.g. most joint injections). I no longer do obstetrics for financial reasons. I received no training in procedures I intended to not perform for whatever reason.

My next post will address one threat to this liberty. 

Monday, April 20, 2009

Make Your Own Parabiotic kit

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Monday, April 13, 2009

Doctish-English Phrase Book

Doctish-English and English-Doctish Travelers' Phrase Book-- Introduction and Initial Lesson

Doctish is a dialect of Medicalese in wide use, however misunderstandings commonly occur with its use. Despite CMS mandates, there remains insufficient availability of translators due to scarcity and expense. Many phrases seem to have the same meaning in English but mean something else entirely. In addition, a superficially similar but unrelated language with many dialects (Alternivarian) causes confusion through similar terms with bogus meanings [ed. note. Although Alternivarian often has Medical or Medicalese appended to its name, it is an Alien toungue from another universe with scant connection with physical reality].

This guide will be published in installments so as to maximize your learning experience and our revenue.

Lesson 1 Common expressions
Doctish phrase / Plain English translation

Hello, I'm Dr. ______. / Let's get on with it. I only have 7 minutes

Who referred you? / Who is to blame?

How can I help you? / What can I do to you?

How did it happen? / You did what?

Which toe is it? / I'm blind.

Where do you hurt? / Where will you hurt even more in a minute?

Lemee feel it. / Minute's up.

Does that hurt? / Stop screaming!

We need to run some tests. / I'm hear lawyers' hoofbeats.

We need to do a diagnostic procedure. / I have a Porche payment due.

This won't hurt a bit. / This will hurt.

You will experience some discomfort. / This will hurt a lot.

I'll give a few pain pills for home. / This will hurt more than you can imagine.

The results are back. / Oh, oh.

I'm not certain, but... / I'm certain.

Do you have an advance directive? / You're toast.

Is there anyone else I should talk to? / You're toast and I need to butter up the next of kin.

I'll send a report to your regular doctor. / I've run out of procedures to do on you.

You can follow-up with your PCP. / Not my problem!

Friday, April 10, 2009

It Takes a Medical Village

The Health Commission®
One Monopoly Parkway
Stoner Brook, IL 67067

April 1, 2009

Dear Hospital Administrator,

Today a new standard for obstetric services was released by The Health Commission®.

The THC® has led American hospitals to adopt Beyond Perfect Care™ as the standard the last several years. Now we have moved on to the next step, the Medical Village concept. Today’s new rules continue that triumph requiring a multi-disciplinary team approach to human reproduction to increase quality offspring and decrease costs.

Team members will include one of each of these specialties:

Specialty Responsibility to the team and expectant mother/donor

Sociologist compatibility for coupling
Psychologist mental health/readiness
Geneticist check for defective genes
Coitupractor prevent defective technique
Fertility specialist successful implantation
Medicaider arrange medical card
Tutor help with school
Gestationist monitor antepartum course
Cert Micturation Asst collect urine samples
Phlebotomist collect blood samples
Malpractitioner collect legal fees
Ultrasonographer assess fetus/determine sex
Nomenclaturist advise on names
Fashionista advise on clothes
Induciologist induce labor
Anesthetist stop labor
Partitionist restart labor & assist
Caesaropath deliver baby
Med Student feel useless
Videographer take the movies
Neonatologist assess newborn
Postpartitionist monitor postpartum course
Social Worker sign up for stimulus money
Grandma take care of infant

All charting will be done using Electronic Maternal Records. Scoring of each birth will be done using the 10 point judging system of the American Gynastics Federation following the guidelines of our Beyond Perfect Care™ rules.

For more information go to our website

Kim McRobert, MD
Multidisiplinary Requirement Team
The Health Commission®

Parasitizing American Hospitals for over 30 Years

Thursday, April 9, 2009

Patient Autonomy vs. Doctor Autonomy

My last post dealt with the simple question of responsibility for one's own health. This follow-up is about one type of conflict which arises as a result.

A person called our office requesting to become a new patient. He wants be referred for hyperbaric oxygen therapy (HBOT) for an old stroke. He also stated that he is happy to stay with his regular doctor for everything else, but wanted to see me since he had heard I use alternative medicine. [note: I have that reputation as I do not argue with my patients over such "woo" unless I believe it to be harmful] 

I declined the invitation. 

The person later that day showed up at the Office front window and argued for 10 minutes with my receptionist about my decision. He only needed a referral to a nearby HBOT center and promised he would take little of my time. Oh, he also wanted to discuss other alternative therapies with me.

He had found a HBOT place in California, but didn't want to pay for the trip, motel, etc. Could he make an appointment so that I could convince the nearby HBOT center (2 hours away, only treating chronic wounds) to treat him for the stroke? "What kind of wound do I need?" 

I continued to decline, and he left unsatisfied. 

An individual has the right and responsibility for their own health. If unsatisfied with one doctor or practitioner or course of treatment, s/he is at liberty to find others to provide the health care sought (providing it is legal).

This man exercised his freedom finding a place for his desired legal treatment from the internet, but wanted a cheaper, more convenient outlet. I exercised my freedom by declining to be involved. He felt I was wrong to do so, that it is my job to help him obtain the health care which he has decided he wants, in the manner desired.

The patient has autonomy (self-rule) to make their own health care choices (within the law).

The doctor has autonomy to make his/her own practice choices (within the law). This includes the mode of practice and under the circumstances s/he decides.  

The self-rule of the patient does not give the right to rule over the doctor.

Monday, April 6, 2009

Who is responsible for one's health?

A most important question behind too many health initiatives and medicrat blather is a most basic one.

Who is in charge?
Who is in charge of a person's health?

Is it the patient?
Is it the Doctor?
Is it the Medicrat?

Do you remember the old rhetorical question, "Whose body is it, anyway"?

When I was in training, I was subject to a great deal of instruction to not be "paternalistic" toward patients and to respectfully obey their autonomy. I could advise, warn, and teach, I could give them options and try to help, but ultimately the patient made the decision for him/herself.

Today, however, we are seeing the erosion of patient autonomy and a forced resurgence of paternalism as doctors are blamed when someone makes 'bad choices'. Pay-for-performance (P4P) schemes where the Medicrat decrees the Doctor is responsible for the patient's smoking, weight, exercise, etc. What happened to the patient's autonomy?

It is not the Doctor's prerogative to steal the patient's freedom.
It is not the Medicrat's right to overrule the patient's liberty.
It is a person's right and responsibility to exercise autonomy; self-rule. And to live (or not) with the consequences, whether good or bad.

“Liberty means responsibility. That is why most men dread it.”
George Bernard Shaw

Saturday, April 4, 2009

April Fool jokes on the Internet

Here are some from this year.

The Guardian drops print edition to publish via Twitter
Econoland-a new theme park
Sasquatch Jerky
A new breed of tartan sheep
Mountain Cleaners in Switzerland

Flying Penguins was from 2008

A round-up of recent years is at the Guardian and at April Fools Day on the Web.

Here is the video of perhaps the most famous April Fool gag of all--the 1957 Spaghetti Harvest from BBC

Wednesday, April 1, 2009

Sub-prime Specialties Bailout

The Obama Administration today announced sweeping reforms of another economic sector threatened by the current recession. In a dramatic and far-reaching decision, a bailout will be attempted of insolvent medical practices which threaten the stability of the health system.

The medical crisis results from excess investment in sub-prime specialties during the 70's and early 80's. The bubble became unsustainable during the late 1990's when primary care prices dropped and doctors found themselves in specialties they couldn’t afford. Despite working longer hours and seeing more patients, they fell farther into insolvency. Many abandoned general medicine altogether, leaving behind blighted patients and devastated communities. Some fled into hospital medicine or to refinance careers in a new specialty .

The current proposal would establish a new regulatory body with broad powers, a moratorium on second residencies, and would subsidize each sub-prime specialist with almost $37.26 per year for two years in an attempt to keep doctors in practice.

Many analysts blame the residencies for the fiasco. “Teaching institutions encouraged sleep-deprived medical students to accept residency contract terms little less than indentured servitude. These predators knew they could market the derivative doctors to other institutions and practices before the bubble burst.” asserts one observer.

Other experts disagree. “As students they knew what they signed up for. They were well aware of the low pay and long hours. We need the Government to be firm and refuse to subsidize such risky behavior.” stated Dr. C. P. Tea of the American College of Remunerology .

However A. Fool, MD says she was enticed by the U.S. Government itself. “Federal policies were a giant bait-and-switch. We students were encouraged to enter general internal medicine and family practice and residencies were paid many Federal dollars to expand training slots. Once we completed training and entered practice, the rules and payment system were changed. We’ve been RUCed.”

The proposal will soon be submitted to Congress.

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