Hal Dall, MD --Outlier Physician

Let Me Rephrase That

2012-01-12T16:56:00.000-08:00

Phone call.
Neurosurgeon declines to perform procedure on my alcoholic elderly patient.
I hang up and turn to my staff and say:

Hal Dall, MD: "Dr. X won't operate on Mr. Y because he's a drunk".
Dr. Dall's staffer: "Dr. X is a drunk"?

The Critical Value of Lab Tests

2011-10-21T11:30:00.000-07:00

Many months ago our hospital "improved" the laboratory critical value list.

In the resulting tsunami of early AM phone calls for critically chronically low albumin levels in the malnourished, high bicarbs in lungers and multiple 3.4 meq/dl potassiums, one test stood out: INR/protimes.

I was called for every therapeutic(and many subtherapeutic 1.6+) INR on my warfarin patients.

I "improved" my results by ordering fewer tests, especially those I expected to trigger a call, until our medstaff successfully pushed back the expanded rules (see here for a study of the problem elsewhere). The INR standard was altered to accommodate anticoagulated patients, so the calls abated. Until today.

This morning I was called for a "critical" normal INR of 0.9 in a (non-anticoagulated) liver patient.

"hCG" Redux

2011-09-29T13:27:00.000-07:00

I've seen much more of the "hCG" nonsense since my previous post.

I had a (very tall and obese) 11 year-old boy brought in by his father's female friend to receive my stamp of approval for "hCG" drops and the 500 calorie diet. She hoped to recruit me in her war against his mother (who refused the scheme, thinking it crazy).

Hal Dall, MD: "It's not appropriate, 500 calories are too few for a growing child".

Ms. Fireworks: (at 100 db) "Why do you want him fat?!? Do you want him dead? His mother is killing him"! etc. [rant]

HDMD: "He needs a balanced, moderately low calorie diet. 500 calories is too low".

Ms.F: "You want him fat? Why do you want him to get fatter?" etc. [rants more]

HDMD: "He'd lose weight on a balanced low calorie diet, and I'd be happy to refer him to a dietician for it".

Ms.F:(at 110 db) "That won't work!! He needs the "hCG"! He can't lose without it! His mother feeds him toasted cheese sandwiches! Is THAT the diet you want for him? Toasted cheese sandwiches? ...[rants longer and louder]

After a sharp exchange she accused me of child abuse for not giving approval to her scheme and she stamped out of the office.

I've not encountered the lady again, but the boy has since dropped from BMI 34 to 30.1 in the 8 months since his mom instituted a 1800 kcal diet with consistent exercise.

The Vast Medical Wing Conspiracy!

2011-04-01T13:52:00.000-07:00

Doctors Conspire to Create Epidemics

Widespread Corruption Revealed By Informants

April 1, 2011
By Justin Kidding and April Fuel
Internet News Service

ALERT!! Your Doctor may be making you and your whole community sick!!

Our multi-hour investigation has exposed a massive conspiracy to spread illness organized by Chicago medical mobsters with corrupt doctors and pharmaceutical companies. Allegations of deliberate infections, kickbacks, and drug company trinkets have been raised by multiple personality insiders.

This elaborate scheme’s structure was revealed by our whistleblowers; “Dr. A”, “Dr.MD” and “Dr.HD” spoke to us on condition of strict anonymity. Each doctor tells an aspect of this many-faceted tale of conspiracy, greed and fear. Due to the sensitivity of the information and danger to our informants and ourselves, we will refer to the nefarious coordinating organization by the pseudonym “the American Mobster Doctor Association” aka the “AMDA”. We have confirmed and expanded on these allegations by consulting Google, Art Bell and Charlie Sheen.

We will start with the testimony of “Dr. A”, who gives the overview. “In spring we get the ‘wishbook’ from the “AMDA” which lists available pathogens. Our association reviews it and we make orders specifying germs and optimal timing of epidemics. It is required that a minimum 25% of the pathogens must be bacteria sensitive to antibiotics. In July we receive the (regionally) adjusted schedule, and the first enteroviruses appear. We order our influenza vaccine which is made to counter the 3 strains “AMDA” is using this year. In the fall, the first epidemics arrive, perhaps via jet contrails or ‘mosquito control’ spray trucks. Often a large daycare is contaminated to start things up or in smoke bombs at football games. Each month we promptly kickback part of our fees from office visits to the “AMDA” to ensure the next germ deliveries”.

How is Big Pharma involved? “The drug companies profit from the antibiotics, flu vaccines and cold medicines sold. They also help breed new flu strains to, ah, influence people to get another shot next year or else”. “Dr. A” adds, “I kept silent for years, but my loyalty ran out with the last ink from my final surviving free drug company pen”.

“Dr.HD” filled in some details. “Outbreaks are staggered around a region to decrease suspicion, the timing consistent with historical patterns. For example I might tell a parent, ‘It’s strep. We always get it this time of year’. Of course we do! As we ordered! Ha, ha, I have too much fun with it. I diagnose ‘what’s going around town’ the very day it started! And people whisper government conspiracy theories about black helicopters and I can smile, knowing it’s really the ‘AMDA’!”

“Dr. A” added, “The government is a party to it, though. Remember the saying, ‘Never let a virus go to waste’? The support of the ‘AMDA’ and Big Pharma was needed for the health care bill, so provisions hidden in the bill will continue the lucrative scheme. Of course there will be return payoffs to politicians from the profits through 'meaningful use' of EHRs. It’s the Chicago Way”.

We asked “Dr.MD”, With so many individuals in the know, how have doctors have kept this secret? She replied, “Fear. Naked fear. We know what they have, and they will not hesitate to use it on stool pigeons. C difficile. Vibrio. Entamoeba. Botulism. Even undercover sources are in danger from Treponema, Chlamydia, HIV, HPV and GC”.

It is as yet unclear whether hospitals are part of the syndicate, having no defections surviving from that quarter. Our questions of the “AMDA”were initially ignored, but after revealing our location were politely denied.

What can an individual do in the face of these threats? Unfortunately very little except wearing a little Japanese-style face mask and keeping your tinfoil hat in place.

There is no refuge from the contrails.

Expensive Ingredients

2011-02-25T14:05:00.000-08:00

Recently a long-time patient asked my opinion of the 'new' weight-loss method becoming popular in our town. She has lost and regained hundreds of pounds over the years, trying various diets without long-term success. She did best with Weight Watchers, but a successful friend convinced her to try the "HCG" diet.

I scanned the pages of propagandvertising (the usual pseudoscientific rationale) and instructions she had been given. The diet was primarily very-low calorie (500 kcal/day) with periods of low calorie (1800 kcal) and had a long list of forbidden foods. No surprises there (as I told her, who won't lose weight on 500 Kcal/day?). In addition "HCG" drops are the magic ingredient- to be taken sublingually in 23 day cycles. HCG drops??

"Can I see the bottle they sold you"?

"Here it is. I paid $40 for it".

I look at the front of the label. " hCG". "homeopathic". I turn the bottle and see this on its side:

I turned the label toward her and she read aloud "Ingredients: Water."

"What! I paid $40 for WATER?!? How dumb was THAT"?

I Want The Drug Of Choice

2011-01-18T10:02:00.000-08:00

A retired teacher recently presented with nontender quarter sized minimally red blotch on her leg. She told of recent treatment for a skin infection at an ED. She had no drainage to culture so was treated empirically with a cephalosporin, the infection rapidly diminishing but she soon stopped the med due to GI side effects leaving this minimal lesion. A few days later she came to my office, seeking further treatment.

Mrs. Surfer:I want linezolid for this. The Internet says it is The Drug Of Choice for skin infections.

Dr. Dall: It's used for severe, dangerous infections with possibly resistant staph. We try to hold it in reserve so we don't breed resistance.

Mrs. Surfer: I want the best medicine, it is what is recommended.

Dr. Dall: I'm not going to give it to you. Your infection is minor, non-threatening, and responded to an ordinary antibiotic and is essentially gone. You don't need a horrendously expensive IV medicine.

Mrs. Surfer:I want the best medicine, I don't care about the cost. I can pay for it if my insurance does not.

Dr. Dall: I'm not going to give it to you, I reserve it for specific circumstances.

Mrs. Surfer:Could you give me IV penicillin then? I won't take anything oral.

MMR Derangement Syndrome

2011-01-06T12:35:00.000-08:00

BMJ published the first article in a series documenting how Andrew Wakefield falsified data to publish a purported link between the MMR vaccine and autism. Please read the article and commentary in full (and future installments as they are published).

A summary from the BMJ article:

How the link was fixed

The Lancet paper was a case series of 12 child patients; it reported a proposed “new syndrome” of enterocolitis and regressive autism and associated this with MMR as an “apparent precipitating event.” But in fact:

Three of nine children reported with regressive autism did not have autism diagnosed at all. Only one child clearly had regressive autism

Despite the paper claiming that all 12 children were “previously normal,” five had documented pre-existing developmental concerns

Some children were reported to have experienced first behavioural symptoms within days of MMR, but the records documented these as starting some months after vaccination

In nine cases, unremarkable colonic histopathology results—noting no or minimal fluctuations in inflammatory cell populations—were changed after a medical school “research review” to “non-specific colitis”

The parents of eight children were reported as blaming MMR, but 11 families made this allegation at the hospital. The exclusion of three allegations—all giving times to onset of problems in months—helped to create the appearance of a 14 day temporal link

Patients were recruited through anti-MMR campaigners, and the study was commissioned and funded for planned litigation

The original paper fueled anti-immunization sentiment, and contributed to decreasing immunization rates and increasing infection rates across the Western world. Although the original paper was retracted last year by the Lancet, and Wakefield was stripped of clinical privileges in Britain, he remains a star of anti-immunization groups.

For his fraud, Wakefield gained fame and filthy lucre (including over $600000 from the legal firm). He remains unindicted, free to peddle his ideas here in the US.

The rest of us have paid a heavy price for these lies, in distrust and alienation between parents and doctors. In millions spent trying to disprove a fantasy. In children with preventable illness and untimely death.

Handled By the Medical Safety Administration

2010-11-19T13:03:00.000-08:00

Rejoice America! Help is on the way to rescue you from those ham-fisted unprofessional exams at airport screenings!

Soon, the Medical Safety Administration (MSA) will emerge from the Obama Health Insurance law to deliver you from unneeded medical screening exams, and will then (certainly) move on to non-medical ports of entry.

The US Preventative Screening Task Force (USPSTF) is the sole arbiter of medical screening in ObamaCare, so here are some highlights of USPSTF recommendations for the bashful:

NO recommended skin checks (visual or using scanner)

NO recommended ovary checks!

NO testicular exam!

NO rectal exams!

NO breast exams! Not even self breast exams!

SO, at your local MSA outpost(aka doctor's office)----no one will "TOUCH [YOUR] JUNK".

When the U.S. puts the MSA in charge of both medical and airport screening, all you hassled travelers can rest easy, at least until we get out the colonoscopes.

Risk Management

2010-10-04T10:58:00.000-07:00

Today a cardiologist's office called. My referred 49 y/o patient refused her scheduled radionuclide cardiac imaging fearing danger from radiation exposure. Perhaps I can convince her that her cigarettes, liquor and methamphetamine are radioactive.

Peculiarities of Class

2010-08-14T13:34:00.000-07:00

Nearly 20 years ago I had a young man present with a fractured a rib from a fall. I noted aloud the codeine allergy "documented" in his chart when I had first seen him 3+ years prior. I've never forgotten his response.

"Doc, I'm not allergic to codeine. I used to say that when I was still doing drugs so I could get Vicoden instead. We'd take 6 or 8 Vicoden at a time to get high, when I tried that with codeine, I'd just throw it up".

Drugs within the same class may (or may not) have significant differences in side effects (as above), intended pharmacologic effects(ditto) and cost. These differences are exploited by every player in the medical care bazaar.

My patient exploited differing intended and unintended side effects of two narcotics.

Drug reps exploit the most miniscule distinction to try to sell me on a product while talking down price disparity.

Insurance companies force choices due to cost while ignoring other considerations, regarding generic (same chemical) and same class (similar chemicals) as synonyms.

Recently I had a patient's spouse who explicitly adopted the latter view and was angry when I tried to explain the distinctions between one of his meds and her proposed substitute. "They're the same, there's no difference, they're in the same class".

The medicrats are smiling.

Dr. Rob's 10 Rules for Good Medicine

2010-05-25T13:20:00.000-07:00

This superb post from Dr. Rob comes via DB's excellent blog. Please go read it all.

A taste:

Rule 2: Minimize

Many doctors and patients have a “more is better” mentality. This not only costs more money to the system, but it can cause harm to the patient. Here’s what I think should be done:
1. Patients should only be seen when a visit is appropriate.
2. Use as few medications as possible, and when necessary, use the cheapest one that will do the job.
3. Order as few tests as possible. No test should be ordered for informational purposes only; the question, “What will I do with these results?” should always be answerable. If it is not, the test should not be done.
4. When changes are made, make only a few at a time. Many simultaneous changes make it hard to tell what helps and what hurts.

If Dr. Rob's rules were followed, we'd waste less money to achieve better outcomes with less hassle and heartache. Contrast these precepts of of professionalism to modern mandates by medicrats.

The "Missing Targets Sign"

2010-03-23T14:16:00.000-07:00

Several years ago I had an elderly patient who was an excellent competitive trap-shooter. He came to my office one day with this specific complaint: "Last weekend I was missing targets and losing to guys who have no business beating me".

He had no other symptoms and had a normal neurological exam, but related that he had fallen a few weeks earlier and sustained a small scalp laceration which was sutured at an ER. His CT scan subsequently showed a subdural hematoma so I referred him to a neurosurgeon for treatment.

When he returned four weeks later for followup he reported, "I'm fixed Doc, I'm beating those guys again".

The Health Commission (THC) Bans "Daily" Orders

2010-03-14T12:10:00.000-07:00

A new standard for Health Care Organizations was announced today by The Health Commission (THC) [formerly known as the Joint].

As of today, March 14, 2010, in medication orders, use of daily, weekly and monthly are now considered a Type 1 violation of patient safety. Medication orders must be written in this format:

x(quantity) every y(time period in hours, minutes, or seconds); e.g. 10mg every 24 hours, or 5ml every 12 hours.

This new rule is necessary due to thousands of overdoses which began earlier today in hospitals across most of North America. Patients receiving medications scheduled for "daily" or "twice daily" administration were dosed one hour early, exposing them to possible drug toxicity. There will be a ripple effect with further inappropriate dosing of "weekly" and monthly" in the next doses. This phenomenon is thought to comprise a large portion of the hundreds of thousands who die each year of medical errors. This can be seen in that there were no cases in Hawaii or Arizona which have 2 of the 4 lowest mortality rates in the USA.

THC has enforced previous crucial safety standards to protect patients from harm such as banning "qd" in typed as well as handwritten records, requiring writing out "magnesium sulfate" instead of its chemical formula, and enforcing the 24 hour rule for signing physician verbal orders.

Note: an equivalent rule will soon cover other orders such as vital signs, therapy, and weighing the patient.

Homeopathic ER

2009-12-21T16:08:00.000-08:00

H/T to Dr. Val and GruntDoc.

Doctish-English Phrase Book: Dialogue 1

2009-11-19T22:52:00.000-08:00

This lesson illustrates a conversation using two dialects of Doctish. The physician, Dr. Lucre uses the standard form, while his patient, Mr. Slippery speaks Evadian. (Translation is provided in italics)

Dr. Lucre: Good morning, how are you today? You're here?

Mr. Solvent: I'm fine I'm here

Dr. L: What can I do for you? Can I make this a 99214? I have a Porsche payment due

Mr. S: You told me to come in for a recheck. You have a Porsche payment due

Dr. L: How has your blood pressure been doing? I see your pressure is high today. It's always high

Mr. S: It's always high when I'm in your office. It's always high

Dr. L: Do you check it elsewhere, is it any different? You don't check it

Mr. S: Once in a while. No Here's my list of numbers. I made them up

Dr. L: We talked before about lifestyle modification. I see you've gained weight, have you been exercising? How about salt intake? You'll blow me off again and I don't get paid for talking

Mr. S: Your scales are off, at home I weigh less than last time. I try to watch the salt. I have this script memorized

Dr. L: Any side effects from your medicine? Can I get moderate risk?

Mr. S: Only the price. Didn't buy it

Dr. L: Any new symptoms in any way? Nope, not even limited risk. I need more HPI elements. Mx/Dx options?

Dr. L: Have you had any chest pain, trouble breathing, edema, etc... ROS x2, check

Mr. S: Nope Nope

Dr. L: Any Family Medical History of hypertension? need 1 pfsh, Check

Mr. S: Not yet. Check your notes, idiot! You ask every visit.

Dr. L: Let me check you over [does brief physical exam]. I need 12 bullets, Check

Mr. S: Why'd you hafta check my ears? He's padding the bill

Dr. L: It's a valuable thing to check. I'll get to charge more

Mr. S: Anything else Doc? Anything else?

Dr. L: I want to double your Hypotensin pill. Take your Hypotensin pill

Mr. S: OK, I'll need a new prescription. I tossed the old prescription

Dr. L: Ok, here you go. I want to recheck you in 3 months. Same same in 3 months.

Mr. S: Ok, 3 months. Same same in 3 months.

Volitional Dementia

2009-10-06T12:19:00.000-07:00

I recently saw an elderly gentleman whose wife thought he might be developing dementia.

To introduce the subject I stated "Your wife is concerned that you forget things. Do you have any trouble with your memory?"

"Not unless I want to."

Ezekiel Emanuel and Medical Rationing- Link

2009-10-05T21:46:00.000-07:00

Ezekiel Emanuel (Rahm Emanuel's brother) is an influential player in health care reform and rationing. I began to write posts descibing his writings, but I didn't complete the pieces, yearning for someone more erudite to do so.

DrRich (the must-read writer on medical rationing) has now published a must-read article on Emanuel here.

BaucusCare: Keep your Doctor?

2009-09-26T21:11:00.000-07:00

Here is a portion of a simple flowchart which allows you to determine if you can keep your doctor if the Senate health plan becomes law. Click this link to see the whole chart. Alles klar?

Update: The chart doesn't seem to appear on the post at times. The original is here.

Background Music for the O.R.

2009-09-07T21:24:00.000-07:00

Here is some excellent stuff!

More at www.laryngospasms.com

Will The ObamaCare Plan Lead to Rationing?

2009-08-13T13:15:00.000-07:00

Current public debate over the Obama/Congress health ~~care~~ insurance reform bill(s) has been increasingly fixated on whether or not health care "rationing" would result.

What is medical/healthcare rationing?

"To ration healthcare is to withhold at least some useful medical services from at least some of the people who would benefit from them." (per DrRich at covertrationingblog.com)

Does the Obama administration's plan include rationing?

Actually, we already have rationing, but it's not usually recognized.

Medical rationing comes in two flavors, covert and open/explicit.

Covert rationing occurs every day, as doctors and hospitals jump through the hoops required by government and insurances to treat people. The various delays, frequent rule changes, preauthorizations, unexplained denials & etc. are rationing methods covertly practiced on thousands of patients every hour. These techniques are designed to manipulate doctors and patients to change diagnosis and treatment plans for the benefit of the insurance company or government budget. Much of the disgust with insurance companies derives from these practices.

Covert rationing is both ineffective and destructive of the relationship people have with doctors. The additional medicrats required eat up any savings. Doctors become seen as a hurdle between the patient and some desired end. I have had many patients leave my practice angry at me when I have been unable to convince a stonewalling insurance company to pay for something. HMOs are a special type of covert rationing where the doctor performs rationing on behalf of the insurer and for the benefit of him/herself.

Open rationing occurs when an explicit decision is made to not cover a useful medical service ( e.g. no dialysis past age X) and is considered by many Americans to be distasteful, even evil. I practice in a state whose Medicaid system developed a controversial explicit rationing system in order save enough money to cover tens of thousands more people. It worked fairly well until the Federal medicrats put the screws to it. Open rationing is a common bogeyman in American politics.

The Congressional plans have no explicit language establishing open rationing. That means that covert rationing will be the main method of attempting to control costs in the system initially, and it will continue to be both ineffective and destructive. As long as people can make someone else pay for their medical care, no one will be able to quench the unceasing appetite of Americans for all possible care, all the time, immediately, for every ailment and symptom (The Happy Hospitalist often states: FREE= MORE MORE=BANKRUPT).

That is a huge flaw in the Obama plan. It can not control the costs because it cannot control the volume (this is a major problem with Medicare/Medicaid). The volume of services can only be controlled by external controls (rationing) and patient choice ( make 'em pay). Controlling waste and fraud are illusory solutions.

Initial attempts to control costs in a national system will follow the line of least political resistance using feeble and infuriating covert rationing, but in the long run will require explicit rationing as other nations have done. Yes, ObamaCare will have rationing, of the irrational kind.

An excellent source for discussions of these issues is DrRich at covertrationingblog.com, everyone interested in these issues needs to read his explanations and analysis.

AWOL

2009-06-28T22:37:00.000-07:00

I'll be on a medical mission for the next two weeks with doubtful internet access for posting.

Until then, hassle Happy (see sidebar).

Treating Me In Dementia

2009-06-28T22:24:00.000-07:00

I had a long-time patient tell me last week that she had a solution for her own future dementia.

She would rig a bomb and wrap it as a gift to herself. If she ever developed dementia, she'd forget what was in the box and open it.

A nurse told me her advance directive includes a provision that if she cannot remember to ask for her medicines, she's not to receive them.

I'd add the exception that the care provider should give me morphine, antiemetics, haloperidol and lorazepam as needed.

Any other ideas?

Does Canada Really Make Patients Wait?

2009-06-23T13:13:00.000-07:00

In the debate about a Government-run National Health Plan, impressions of the Canadian system loom over any proposal. The influence can be subtle, educated, or not. Often it degenerates into the exalted format of childhood arguments:"Does!" "Does not!" "Does too!" etc...

Waiting times for certain tests and surgery are thrown about and highlighted or trashed, but rarely is any data offered. Here is the 2008 Fraser Institute report "Waiting Your Turn", which provides a comprehensive look at the numbers. Take a look at it, some of the best graphs of the overall effects are on pages 57 and 58.

Highlights of the report include an average 8.5 week wait from referral to seeing a specialist, and another 8.7 weeks to receive the treatment recommended by that consultant. One of the shortest waits was medical oncology (think chemotherapy) which was 4.6 weeks from referral to treatment. Overall the wait times nearly doubled compared to 1993 (referral to treatment went from 9.3 weeks to 17.2 weeks in 2008).

One can well argue whether these waiting times are medically significant or not, whether this person or that person might have "had an untoward outcome" as a result.

My point instead is that Canada's medical system is not the health care nirvana that some claim. Canada has rationing by an ever lengthening queue.

No national health care system can afford to pay for everything, for everyone, always. All the handwaving about 'efficiencies' and EMRs will not conjure enough cash to prevent rationing, whether open or covert.

When The Consultant Is Non-Compliant

2009-06-16T13:21:00.000-07:00

Pay for Performance (P4P) and the Patient Centered Medical Home are two of the schemes being touted to save the nation from nefarious, inept and greedy doctors. Chief among arguments for these ideas are that more structured routine medical care will "increase quality" and "reduce health care costs". In essence, reward docs to do what 'someone' wants them to do (and imply future penalties if they don't).

An example of this approach is to reward (or not penalize) primary care doctors(PCP) for blood sugar and A1c "targets" achieved by their diabetic patients, typically A1c <7 and fasting CBGs <120. The PCP is rewarded or not based on the group performance of patients with the condition as though he/she is the only variable in the equation.

I have a middle-aged patient who elected to seek and receive surgical treatment for obesity in part because he had inadequate control of his diabetes (A1c 7.5-8) despite multiple medications, etc. He had no A1c (7.9) and CBG (~140 fasting) improvement after surgery, so the surgeon obtained a medicine/endocrine consultation(I was not involved). My patient is motivated and compliant with both medications and lifestyle choices.

The consultant recommended that my patient discontinue his diabetic medication as long as his fasting CBG stays below 180!

Now, if my patient chooses to follow the consultant's wisdom instead of my recommendation leading to worsened A1c and CBG numbers, should I be held financially responsible, as the PCP, for my patient's failure to meet the goal? Should my name go on the bad doctor list? Should I fire the patient?

Why Should I Care If Physicians Lose Autonomy?

2009-06-12T16:59:00.000-07:00

How does the loss of the conscience clause threaten physician autonomy? How would that affect me?

The loss of the conscience clause is simply one more nail in the coffin, but a crucial one. It marks the transfer of decision making from the doctor and patient to 'someone'.

The someone will be a government medicrat.

If the medicrat has the power to determine what services the doctor must provide, he/she has the power to determine what the doctor cannot provide.

If the doctor is forbidden to provide a service, the patient cannot receive it.

Where does this already happen? Look to Canada, where all medical care comes through the government system, and physicians are prohibited from operating outside the rules. Most Americans know that Canadians can wait months for many tests and surgeries because Canadian doctors have been prohibited from providing care except by the medicrat rules (although a recent court decision has led to cracks in the concrete). If someone wants the hip surgery sooner, they must leave the country rather than wait.

Currently in the USA, a government program or insurance company can decide to "not cover", that is, not pay for a service. The doctor may recommend, and the patient may decide to have a service and pay for it out of pocket. Although this can be inconvenient and expensive, the final decision is made by the patient. The patient preserves his/her autonomy, as does the doctor.

No national health plan can pay for everything, all the time, for everyone, although the politicians will pretend for a time. As expenses run away, the pressure to lower costs will lead to intensified hidden rules and restrictions (covert rationing) and eventually to explicit rationing. The current "not covered" will increasingly morph into "not medically necessary". Will it become forbidden?

Insist that any plan protect this freedom: that when your surgery/test/procedure/consultation is denied or delayed, you have the liberty to pay out of pocket without leaving the country.

Otherwise, expect your bladder difficulties to be treated by Vogon poetry.

Saving Medicare and Social Security

2009-06-08T23:21:00.000-07:00

We need to encourage (=pay) all the Boomers to try this.

Doctor Automomy Vs. Patient Autonomy

2009-05-08T16:19:00.000-07:00

What should happen when patient autonomy and physician autonomy appear to conflict?

What if my patient requests a procedure which I believe is wrong to perform? Which is against my conscience?

The Obama Administration has recently proposed removing the new Bush-era regulations concerning the "Conscience Clause" protections for health-care personnel and abortion. Many electrons have been rearranged in internet debates in discussions (usually) narrowly focusing on whether doctors may refuse to provide or refer for abortions.

Limiting debate to abortion allows the many venting spleens to miss the critical point: there is no conflict in reality, rather a division of responsibility.

My position is straightforward. The patient has autonomy and the responsibility to decide what legal medical services to seek. The physician has autonomy and the responsibility to practice in the manner s/he chooses. As a physician, I choose whether to provide or refer for any legal procedure or service for my own reasons. If I decline to refer for a procedure, the patient is free to seek care elsewhere in this very commercial society. If it's abortion, must I walk her fingers through the Yellow Pages?

"But doctor, don't you have a duty to provide what the patient wants"?

No. I have a duty to provide medically necessary care to my patients within my scope of practice under the conditions I determine within the law. If a patient, an insurance company or the government requests my services otherwise, I have the right and, at times, the duty to refuse.

My conditions include obvious items such as my training, skills, location, payment and time of day (I have voluntarily limited myself in some contracts and agreements), but also include my belief systems and ethics.

My responsibility is to answer these questions in each individual case:
What can be done?
What needs to be done?
What should be done?

These answers cannot be separated from either my clinical judgement or my ethics. Many similar situations have critical ethical differences we hide in other language. For instance, how many pronouncements against the "octomom" fertility doctor were couched in medical language such as "it was not indicated" when meaning "it was wrong and should not be done"?

Is it wrong to refuse "octomom" multiple embryos on moral grounds?
Is it wrong to refuse clitorectomies?
To assist suicides?
To refer for abortions?

The patient is free to seek these services. I am free to decline.

As I would not be a slave, so I would not be a master. This expresses my idea of democracy.
Abraham Lincoln

Doctor Autonomy

2009-04-24T14:07:00.001-07:00

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.

Make Your Own Parabiotic kit

2009-04-20T17:09:00.000-07:00

The NEW! ALL-NATURAL! ORGANIC! Way to Maintain Health!

Introducing the

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1) Take a loaf of Organic Whole Grain Bread and wet with pure bottled spring water
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4) Eat one slice twice daily for health maintenance and 2 slices four times a day for illness

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Not to be used by those with a penicillin allergy

Doctish-English Phrase Book

2009-04-13T23:18:00.000-07:00

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!

It Takes a Medical Village

2009-04-10T11:22:00.000-07:00

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 www.chickencheck.org

Kim McRobert, MD
Multidisiplinary Requirement Team
The Health Commission®

Parasitizing American Hospitals for over 30 Years

Patient Autonomy vs. Doctor Autonomy

2009-04-09T19:13:00.000-07:00

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.

Who is responsible for one's health?

2009-04-06T16:50:00.000-07:00

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

April Fool jokes on the Internet

2009-04-04T17:00:00.000-07:00

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

Sub-prime Specialties Bailout

2009-04-01T20:41:00.000-07:00

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.

Our Sponsor and my hope for retirement!

2009-04-01T18:57:00.000-07:00

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