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Health Care


The Mission

It's a big job, but it's sure a lot easier when I have my nurses and my patients rooting for me and helping me achieve this goal.  Really.  I cannot express just how much better life is in this practice than it was in my old one.  From what I've heard, things are just getting worse in that world.

It's my mission to help pave a road to a better way.  I am grateful to have not only nurses on my side, but patients joining in this mission.


Gaia and Snake Oil


Gaia and Snake Oil

The idea of a 'balance' to be disturbed flies in the face of the reality easily seen in this world: few people get through the year without getting sick, and none ultimately avoid getting some terminal condition.  In short, fighting sickness is always a losing game.



Adventures in Medicine, Part 2

IMG_0481 In case you missed my last post (some may consider it a blessing, like missing the season premiere of "Jenny McCarthy, the science Gal"), this is the star of the show.  His name is "Chuck."

Why, many may ask do I use "quotes" when I use the name "Chuck."  To this, I respond, that it's a "secret."  Maybe you should get a "life."

IMG_0480So when last we left Chuck, he was in the office of his "Primary Care Provider," Dr. Ron.  Chuck fell over his cat and injured his back.  He didn't think he had a problem that needed a doctor's attention, but when he went to the Internet for answers (which everyone does, in case you didn't know), he only got more confused (and a little scared).  He needed advice from someone he trusts, and, despite the wait times and co-pays, he likes and trusts Dr. Ron.

So, being the good soldier within the patient brigade, Chuck takes the whole afternoon off and sets his mind toward the exciting prospect of the hours of excitement at Dr. Ron's office.

2013-08-20 15.03.55

Despite the seeming reality TV scene in the waiting room, Chuck is happy to be in a place where he can get concrete answers to his questions and an end to his pain.  For Chuck, as with most patients, the visit to the doctor should go like this:

Step 1:  Chuck tells the doctor his problem.  Doctor Ron listens and knows what is wrong.


Step 2: Doctor tells Chuck what is causes his problem and comes up with a solution.


Step 3: Problem gone, Chuck can once again pursue his dream of being center fielder for the Toledo Mud Hens, and Dr. Ron is thrilled to be part of his success.


Not to be outdone in the expectations department, Dr. Ron expects the visit to happen like this:

1. Patient has questions and problems which Dr. Ron answers and solves (respectively).

IMG_06392.  Patient happily pays for the encounter, as do all his satisfied customers.


3. Successful in medicine, Ron turns to his hidden fantasy: to compete on (and win) the popular "Doctor Idol" TV show.  His patients are proud of him.


So what's wrong with these pictures (besides obvious anatomical inconsistencies, such as the regular disappearance of noses)?

Stay tuned....



Crazy Ideas


A patient calls or emails me with a problem.  I talk with them over the course of a few days, using whatever form of communication works best.  Eventually, they need to come to the office to be seen - either for something needing to be done in-person (examination, procedure, or lab test), or because of the advantages of face-to-face communication.  At the visit, I not only deal with one problem, but there are other issues needing to be addressed.  Finally, after the visit, follow-up on the problem continues until it is either resolved, or at least is not causing much trouble.

So how do I document that?

In the past I would've had a clear structure for the "office visit" and separate "encounters" for the documentation of the communication done outside of the office.  The latter would be done largely with narrative of the conversation, and some direct quotes from the patient.  The former, the "office visit" would include:

  • A re-telling of the story of the "chief complaint" and what's been happening that caused this encounter to be necessary.
  • A sifting through other symptoms and past-problems to see if there is any information hidden there that may be useful.
  • A documentation of past problems (already in the record) to support the thought process documented later in the visit.
  • An overview of the physical exam, again to support the  decisions made as a result of the visit.
  • A discussion of my thoughts on what I think is going on.
  • A telling of my plan on how to deal with this.
  • A list of any advice given, tests ordered, medications changed, prescriptions written, and follow-up as the details of that plan.
  • A signature at the end, attesting to the validity of what is contained in the note.

But here's the problem: it's not real.  I don't make all of my decisions based on the visit, and the patient's story is not limited to what they tell me.  Details may be left out because they are forgotten, questions aren't asked, or things just haven't happened yet.  This signed and sealed unit of care, represented as a full story, actually represents only fragments of the story, of many stories actually, and only as a moment on the continuum of the patient's care.

But there it stands, the office visit, the center of the patient's medical record.  It is what my past life defines as "health care."  But for me now, it is an anachronism: an old-fashioned idea that has nothing to do with my present reality.  My care is no longer episodic, so why should my records be?  I no longer need "visits" as units of commerce, and no longer need "problems" as the goods for which I am paid.  This took me quite a while to figure out, and has me making some radical (crazy?) changes to how I think about care.

1.  Stop Artificially Defining Units of Care from My Perspective

The "office visit" is a unit defined from the physician's perspective.  This may actually undermine a clear thought process, though, fooling me into believing I've finished something that isn't complete.  Instead of breaking care into a temporal unit, why not define it another way:

  1. The narrative - what is going on with the person.  The patient narrative goes over their lifetime, some of which happens in my office.  Narrative would best be a combination of patient input and my observations as a third-party.  My job is not necessarily to do the narration, but to guide it by asking questions and to prioritize that which I think is most salient.  Each "problem" may have its own narrative, but those lines often blur, as the chronic disease causes depression, and both the chronic disease and depression lead to fatigue and increased pain.  How do you divide those?  Do you need to?
  2. The investigation - both through my questions, examination, and through tests I order, I work to solve puzzles.  The patient wants me to make sense of confusing parts of their narrative, so I step in and investigate.  Tests are ordered for a reason, and exams are generally problem-driven.  One of the most important "tests" to do is to wait and see what happens.  Sometimes stories only become clear as they unfold, and it is my job to know when it's best to do nothing other than wait and observe.
  3. Interventions - medications, lifestyle changes, education, and procedures are what most people think of when they define "health care."  Yet these are entirely driven by the narrative and investigation.  They add to the narrative and often become part of the investigation, but they never stand alone.  Well, they shouldn't stand alone, despite the fact that they are what doctors are largely paid for in this country.
  4. Destinations - what are our goals?  What is the goal of the patient in the bigger sense, and what are our goals for individual narratives?  The destination is the entire purpose of the doctor-patient interaction.  The patient doesn't like their destination and I am called on to help them go somewhere else, or they just want to be sure they are not inadvertently going to a bad locale.

Can I do a record based on these categories?  If I do, would it end up as a crazy jumbled mess?

2.  Find Strings to Tie the Pieces Together

Each part of the record of care is tied together in different ways, with different things that they share with the other pieces of information or narrative.

  1. Diseases - these were referred to as "problems" in my past life, a euphemism if there ever was one, but part of each record is usually devoted toward the prevention, treatment, or management of disease.  Narrative, investigation, intervention, and destination could address these aspects of disease.
  2. Symptoms - these also (perhaps more appropriately) were listed as "problems" in my past life.  They are how health directly impacts the patient.  Symptoms may or may be related to a one or many diseases, or may be mysterious.
  3. Risks - These are sometimes determined by choices of the patient (smoking, drinking) or not (family history).  The reason we at all care about smoking or family history is the risk they confer.
  4. Events - Big events, such as heart attacks or motor vehicle accidents can result from or cause disease, but they are tied together in a temporal way.  In the same way, an office visit is a temporal way to tie together interactions with a patient on a given day.  (I didn't say it's entirely bad to consider visits as units; it's just bad to only define them that way).
  5. Situation/Environment - What's going on in the other areas?  Is the person getting a divorce?  Is it allergy season?  Is there a flu epidemic?
  6. Population factors - some narratives, investigations, interventions, and destinations can transcend a single patient.  My ability to see the population as a whole will help me to give better individual care.

Where does this lead?

What does a record in such a world look like?  I can't say I've come to a clear idea, but there are some things I've started doing:

  1. Treating narrative as a separate entity - Whether communication happens via secure message, on the phone, or via email, narrative is narrative.  It is the fuel that propels good communication (my listening to it) and by which proper care is given.  Lumping narrative with the other areas tends to artificially categorize it.  The result is a separate documentation of narrative from exam, intervention, etc. in the record.
  2. Tying narrative and the other areas together using things they have in common.  I have started using diseases, symptoms, risk factors,  and events as tags, tagging narrative, consults, lab results, medications, and anything else with these fathers (so I can see all conversations, examinations, lab tests, consults, hospitalizations, etc. related to a person's diabetes, for example, or seeing all other parts related to a specific medication).
  3. Allowing free-flowing use of tags to give me different views of the same parts of the record.  In general, the more perspectives one has when looking at something, the more accurate the picture.  This means tagging needs to be simple (perhaps automatic) and robust.  It also means that I need to be able to quickly get those views when I (or the patient) need them.
  4. Working with the patient to come up with a destination - an overall plan of what they expect to get out of my care.
  5. Going over the progress toward those destinations on a regular basis.
  6. Making all of this fully available to my patients.  This assures the accuracy of the information and keeps it focused where it should be: on the person for whom this whole system is built.

Sounds crazy?  Sometimes I wonder.  But then I look at what my past life as a doctor involved, and what "care" was defined as, and I begin to grin.  That was crazy.  This is simply being myself, which, for once, doesn't seem so crazy.



More Trouble

I remember going to see the movie "Oliver" in the theater when I was a kid.  Since this was my first movie in a theater, my mom made me a treat: a bag full of raisins and chocolate chips (Raisinets for Dutch people) and sent me there with my sister.  It was a fine film, with Oliver getting kicked out of the orphanage when he wanted more gruel, the dastardly Bill Sykes threatening Oliver and sweet Nancy, the funny and clever artful dodger and Fagan teaching Oliver about life on the street, and with (spoiler alert!) good overcoming evil in the end Oliver getting adopted by a rich dude so he can get all the gruel (or real Raisinets) that he wanted.  And though my memories of the movie are still vivid, my strongest memory was the look on my sister's face when I walked out of the theater covered with melted chocolate chip goo.  It went into family lore (and wouldn't have happened if they had sprung for Rasinets, I might add).  I think they still don't trust me with chocolate chips.


The key line in the film comes when Oliver loses a bet and goes up to the gruel-master and says: "Please Sir, I want some more."  Which, as I am sure Oliver expected, causes the gruel-master to break into the song, "Oliver! Oliver! Never before has a boy wanted more!" and the whole dining hall to pull out musical instruments and singing harmony to the gruel-master's admonition.

I can see why Oliver was scared.  A whipping is welcome compared to his whole world breaking into song and dance.


Asking for "more" has caused trouble over the ages.  Adam and Eve wanted more food choices, the people of Pompeii wanted more mountain-side housing, Napoleon and Adolph Hitler wanted to spend more time in Russia, and America wanted more of the Kardashians. We can all see what destruction those desires reaped.

Americans have been viewing health care the same way, always wanting more: more antibiotics, more technology, more robots doing more surgery, more expensive treatments for more diseases.  The result: health care costs more in America than anywhere else.  Some folks think that our "more" approach makes our health care "the best in the world," after all, where else can you get so many tests just by asking.  MRI's for back pain, x-rays for coughs, blood tests for anyone who dons the door of the ER.  "Tests for everyone!" shouts the bartender. "Tests are on the house! "

They aren't, of course, and we are paying the price for "more."  This hunger for "more" is fueled by the media's fascination for the "latest thing," the long disproved idea that technology will solve everything, and docs who aren't willing to take time to explain why it's actually better to do less.  It's hard to do, when we are paid more to spend less time with patients, and when the system is willing to pay for more and more.

There is a voice against this: the "Choosing Wisely" campaign, which argues against unnecessary treatments and tests.  This is a welcome voice of reason in the cacophony of cries for "more."  Yet the battle goes against the irresistible tide of our payment system.  The root problem is this: there are a whole lot of people whose jobs depend on America's addiction to "more."  The payment system has created an ecosystem that thrives off of waste (of which I once wrote an allegorical fantasy).  True health care reform will be catastrophic to many who work in health care, with many very nice and hard-working Americans losing their jobs at the ACO factory, at Meaningful Use Inc., and even at Stents-R-Us hospital here in my home town.

This is what you get when you make disease more profitable than health, when we treat problems instead of people.  The simple fact that our system would be destroyed if everyone got healthy should tell us something is terribly wrong.  Doctors want their offices full, not empty.  The goal of every patient - to be healthy and to stay away from the doctor - goes directly against the economics of "more."

I have always tried to be a non-test orderer.  I was trained well by docs who believed it weak-minded and bad care to blithely order tests and prescribe medications without a well-defined reason.  This has always made it harder for me, as it's far more time-consuming to explain why a drug or test is not needed than to simply order it.  But in my new world, one in which an empty office is a good thing, I've found my patients much more open to my aversion to "more."  The main reason for this is that I am giving them more of me.  More of me means they can call if they don't get better, or if their symptoms develop.  They know I won't force them to take more of their time and spend more of their money to get my attention.

Ultimately, I want my patients to see as few doctors, be sick as infrequently, and be on as few drugs as possible.  I hope to wage an all-out assault on "more."

Here are my rules to battle "more"

  1. Never order a test that doesn't help you decide something important.  Ordering tests "just to know" does much more harm than good.
  2. Use consultants only to do things you can't.  Orthopedists will aways give an NSAID and physical therapy for problems, so I don't send patients to them unless they've failed those treatments (where appropriate).  I am just as good at ordering PT, and am more careful with NSAID prescriptions than they are.
  3. Don't give a patient a drug without explaining to them why they need it.  If I can't make a good case for a drug, I shouldn't be giving it.  This is not simply "to lower your cholesterol," or "to treat your blood pressure," but because doing so will raise your life-expectency.
  4. Remember the number that really matters: how many birthdays a person gets to celebrate in health. I don't care about blood pressure, LDL, or even A1c if treating it doesn't raise the birthday total.
  5. Don't forget about another number: how much money patients have in their wallets.  There's no point in ordering a drug they can't afford, or making them pay for a test they don't need (even when they ask for either).

I hope my new world of less overhead, less regulation, and less antacids for me continues on this trend toward less sick patients, less drugs, and less tests.  Perhaps I need to break into a song and dance number whenever my patients ask for "more."

That would teach them.



Trickle Up Economics

It's been a month since I started my new practice.  We are up to nearly 150 patients now, and aside from the cost to renovate my building, our revenue has already surpassed our spending.  The reason this is possible is that a cash-pay practice in which 100% of income is paid up front has an incredibly low overhead.  My admitted ineptitude at financial complexity has forced me to simplify our finances as much as possible.  This means that the accounting is "so simple even a doctor can do it," which means I don't need any front-office support staff.  I don't send out bills because nobody owes me anything.  It's just me and my nurse, focusing our energy on jury-rigging a computerized record so we can give good care. Our attention to care has not gone unnoticed.  Yesterday I got a call from a local TV news reporter who wanted to do a story on what I am doing.  Apparently she heard rumor "from someone who was in the hospital."  I was the talk of the newsroom, yet I've hardly done any marketing; in fact, I am trying to limit the rate of our growth so I can focus on building a system that won't collapse under a higher patient volume.  I explained this to the disappointed reporter why I was not interested in the interview by telling her that I left my old practice because I needed to get off of the hamster wheel of healthcare; the last thing I want to do now is to build my own hamster wheel.


I've also gotten interest from a place I didn't expect: local specialists.  I always thought what I am doing applies only to primary care, as it is hard to do a monthly fee for the procedure-oriented specialties.  But as the enthusiasm for my new type of practice grows in the community, it may spur a boom in cash-paying patients.  Why?  One of the provisions in the Accountable Care Act (ACA) is that small businesses (with over 50 employees) who want to avoid the penalty for not having insurance can opt to contract with a direct-care physician like myself in conjunction with a high-deductible health care plan.  Even though I have made no effort to attract such interest, I've already been approached by 2 businesses of 100 employees to make such an arrangement.  Again, I turned the offer down for now, saying I am quite interested, but would only do so when my practice was ready.  But the fact that this happened while I am doing my to best avoid attracting such attention suggests to me that the desire for this is very intense in the small business community.  This makes sense, as they don't want to pay the fines, but also don't want to pay the exorbitant cost of standard insurance, and so would jump at any other option.

The end result is a potentially large influx of patients who are basically self-pay.  The specialists, who see me lowering my overhead significantly by taking cash payment up-front, see the same opportunity for their practices.  The hitch for them is that they are not allowed to give discounts to self-pay patients that they are not also giving to Medicare patients.  Yes, it is illegal for a Medicare provider to give a discount to non-Medicare patients who cannot afford the cost.  There are ways around this rule, and I hope to work out something for my specialist colleagues so they can give significant discounts in exchange for cash up front (which is, by the way, the same logic that the labs use to give the enormous discounts I am offering to my patients on lab services).  I have had multiple specialists show very high interest in such an arrangement.  I'll fill you in as this develops.

This seems quite ironic to me - a sort of "trickle-up economics," where I am spreading the benefit of offering discounted care in exchange for cash to the higher-paid specialists.  It is a win-win-win arrangement, though, as the specialists benefit from reducing their overhead while getting guaranteed payment, I benefit by increasing the value of my type of practice even more to my patients, and the patient benefits by getting cheaper care.  This, of course, raises the likelihood that more businesses will opt for this payment model, and the movement gains momentum. Who loses?  The "increased overhead" comes in the form of the front-office staff doing billing, coding, and collections.  This is the staff my simple-minded approach to finances has heretofore avoided, and hopes to continue avoiding.


I may be completely wrong in this, as it may not consider other factors (which wouldn't surprise me), but I am not wrong about the intense interest I see in what I am doing.  It is palpable.  When I spoke at HIMSS over the weekend (ironically as keynote for a pre-conference targeted at large health systems building ACO's), the reception was remarkably positive.  My message of simplicity is falling, apparently, on very fertile soil.  Did they realize the implication of "cost savings" being the need for less employees and the to downsize their business?  I took great pains to emphasize the point, yet the reception was vigorously positive.

I suppose little should surprise me, in a world where the have-less's could have their abundance trickle up to the have-mores.  Who knows, maybe people will even pay attention to the economic wisdom of a doctor with an accounting impediment.

Nah.  That's ridiculous.



Patient Rights

I was talking to a patient a few days ago who was raving about a local grocery store.  "They get it," she said.  "They understand how to take care of their customers." It made me think about how far medicine has drifted away from the same idea.  Ironically, despite the fact that our "customers" (people who pay us for our services) are seeking us so we can "take care of" them, we do a lousy job of taking care of our customers.  It has been an obsession of mine since I started practice, but it has been something that has been increasingly difficult to accomplish.  I now have to fight against the need to meet "meaningful use" criteria so that I can have time to make the record meaningful and useful to my patients.  I have to fight against the need to conform to "medical home," criteria so  that I can make my practice the place my patients see as their ultimate medical haven.  The more the government and insurance industries push me toward focusing on my patients, the less time I have for my patients because of the need to meet criteria proving that I am caring for my patients.

It's a mess.

So I went back to my roots.  What do I really think should be the rights of my patients?  Here is a list that I made:

Patients have the following rights:

  1. The right to have access to care when it's needed
    1. This does not mean the care is done in the office either.  It can be done over the phone or via computer.
    2. The schedule of the office should accommodate the patients' needs as much as is reasonable to expect.
  2. The right to have care that is convenient
    1. They should not have to wait to be seen or wait on the phone to be heard
    2. They should not have to come in for problems that can be handled at home or work
  3. The right to have a doctor who is not motivated to have sick patients
    1. Having a doctor with the same motivation as the patient: to keep the them healthy
    2. Having a doctor who does not only react to problems, but works to prevent them
  4. The right to get care that is not rushed or distracted
    1. Visits are as long as they take to deal with the problem
    2. Phone calls aren't cut short from fear of offering "free medicine"
  5. The right to be treated as the one paying for the service of the doctors and their staff
    1. Patients should be satisfied with the "customer experience" in their doctor's office.  They should feel like they spent their money wisely.
    2. They should never feel like a "number" or that the visit revolves around the doctor.
  6. The right to have care that pays attention to cost and does not overdo care
    1. Good care does not mean overdoing it.  Good care means offering the care that is best.  Sometimes (often) that means doing nothing.
    2. Expensive labs, tests, and drugs should always be considered as to the benefit they offer versus the cost they incur.  
    3. The patient should be able to make an informed decision regarding the care they get, increasing their investment in following-through on things.
  7. The right to have access to all of their records at any time
    1. Online access to records is a must.  The lab tests do not belong to the doctor and doctors shouldn't be afraid of the patients seeing them.
    2. The part of the chart (most of it, actually) which the patient knows more than the doctor should be available to edit and control by the patient.
  8. The right to have a doctor who knows what is going on with them
    1. This means that the PCP should always have accurate information about any other care the patient has received.  Because of the state of our system, this does put some burden on the patient to communicate with the doctor.
    2. This means that all specialists should know why the patient is being sent.
    3. This means that hospitalists should know what's going on outside of the hospital and the PCP should know what's going on in the hospital.
    4. This means the PCP should regularly review patient records to know if care is being missed.
  9. The right to understand their care and not be afraid to ask when they don't
    1. Every visit should end up with a clear plan.
    2. Preventive services should be clearly understood and spelled out as to when they are due.
    3. The patient should have access to the doctor if confusion arises and get a quick answer to any questions.
    4. No care should be given without a good explanation.
  10. The right to be treated with empathy and respect
    1. Medical professionals should understand that it's hard to be sick, to have pain, and to die. 
    2. The interaction between doctor and patient is a human interaction - the interaction between to flawed individuals.  This means an expectation of perfection on either side will only result in bad care.
    3. Patients should never be afraid they are going "to get yelled at" by their doctor.  They should feel free to be open when they don't do the right thing.
The biggest irony is that making this list allows me to meet some of the criteria for "Medical Home," and future criteria for "Meaningful Use."  Great.  Check that off of my list.  The problem is that both of these criteria I am working on meeting have a net negative effect on my patients by making me more busy in checking off tasks and reporting data, giving me less time to actually give my patients these rights.
So what do you think about this list?  How should doctors work toward patient rights in a setting where we are increasingly burdened with criteria to prove we are meeting them?  How can we meet criteria when they themselves are one of the things keeping us from meeting their own goals?
I want to know what my patients want and what they need.  My ultimate goal is to meet those needs like the grocery store is doing, offering such good service that when my patients go to the grocery store they brag to the people there about the good care they get from their doctor.
Imagine that.



The Food on the Titanic

Health care is broken.  Badly broken.  I was making a list of areas in which the system is broken (not human error, but system error), and I got up to 53 in one sitting.  When I tweeted this, a good friend and fellow blogger wondered why I didn't start a list of things that are right about health care.  I pondered a bit whether I was just being a nabob of negativism.*  Surely there are good things about our system that balance the bad. Well, there are definitely positive things, especially the people who work in medicine, but I don't know if their existence "balances" out the bad.  It's like saying the quality of food on the Titanic was great.  Or it's like saying that, despite your terminal cancer, your skin looks fabulous.  Both of these facts may be true, but you had best consider the negative first and address it if you can before you dwell on the positives.

On the other hand, I don't want this blog to turn into a whine-fest.  A voice that is only critical will soon be ignored.  So I am going to start two series of blog posts: one focused on the negatives, and one focused on what I like about being a doctor.  I should point out that I have always tried to share the joys I find in medicine (like my most recent post, for example), but I do think my voice needs to be balanced.  The problems still greatly outweigh any positives, just as the sunken ship will ruin the food and the cancer will eventually destroy the skin.

But if I start to sound whiny, please let me know.  The reason I am pointing out the negatives is because I firmly believe two things:

  1. Most people don't have any idea just how broken the health care system is.
  2. There are solutions to many of the problems - solutions that are not being talked about nearly enough.

In the end, I am an optimist.  I also like to fix things.  I hope the negative tone doesn't drown that out.

* 1 point if you know the historical significance of this term




One of the main things driving  me back to blogging is madness.  While I can’t be sure that I am not overcome by madness, it is not my own of madness I am referring to.  Well, no, I am mad, but not mad in the way that I hear Elvis whispering in my ear or think that the squirrels are evil robots put there by aliens to spy on us.  The squirrel theory may be true (evidence does strongly support it), but it’s not that kind of madness I am talking about.

I am angry at the madness of our system.

I am angry when patients come to me after a two week hospitalization and I have no records or even an idea that they were hospitalized.  I am angry when I have to rely on my patients to find out what happened at the specialist, the emergency room, or in the hospital.  I am angry at all of the money that is being wasted on useless and sometimes harmful care and is done because nobody knows what is going on with patients.  I am angry when my life is spent chasing around ever-changing drug formularies and drug “shortages.” I am angry when my patients have to wait for a three-hour visit with a specialist who I recommended, only to have their complaints ignored and their questions unanswered.

I am angry about the political game of chicken that is regularly played by congress with Medicare reimbursement.  I am angry that it is far more lucrative to document than it is to care for patients.  I am angry at all the time I spend more time every day dealing with rules and regulations I don't understand than I do deciding what's best for people's health.  I am angry that electronic record systems pay more attention to "meaningful use" certification than they do to making their systems be useful in a meaningful way.

I am angry at doctors who prescribe narcotics like candy and then send me their patients when the DEA investigates.  I am angry at patients who try to fool me into prescribing drugs they are not taking, but selling.  I am angry that there are no psychiatrists available and so I am forced to perform amateur psychiatry on them in a 15-minute visit.  I am angry that my patients assume their doctors know their medical history when they don't, and that doctors assume the patient knows their medical history when they don't.

If any other business operated like health care, it would go out of business and the people who ran the business would go to jail.  I am serious.  People are gouged by our system and are given terrible care in return.  More and more I am seeing why people no longer trust the medical community and are turning to alternatives.  If our system is treating them poorly, they find someone who will do otherwise. I can't blame them.

And guess what, folks; it's an election year!  Prepare for more madness.  Prepare for politicians who prey on the fear of the elderly by telling them the other party wants to kill them.  Prepare for simplistic, head in the sand solutions to the problem that avoid the real problem because doing so would lose votes.  Prepare for promises of bigger, better programs that will fix our bloated system.  Prepare for complete madness transformed by political spin to look like rational policy.

Yes, there is a lot of madness to be had.  Everyone can have their fill.  The fire hose of madness is waiting to knock over whoever stands in its spray.

All of this makes me sad.  I am sad because I sit in the room every day with people who are pummeled by this madness.  I am sad because the madness hurts people I am trying to help. I am sad because I know of things I could do to decrease the madness for my patients, but would be rewarded with a decreased salary.  I am sad because I have to choose between making a living for my family and giving the best care possible.  I can't have both.

People need to know how dysfunctional our system is, not on a political or sociological level, but in the reality of the exam room.  This madness is making the most committed doctors have second thoughts about their profession.  I didn't go into medicine to learn to "play the game."  We all deserve better than this.

Don't worry; I don't intend for this blog to be a whining rant.  I wouldn't have come back to blogging just to complain about problems without giving hope.  There is hope, but few people see it.  Perhaps the biggest tragedy is that many if not most of our problems do have real solutions.  I want to beat the drum of sanity.  I want to bypass the spin and rhetoric, the editors and publishers with agendas, and tell you what I see here.  At some point the little boy needs to speak up about the emperor's nakedness.  There are others saying it, but the voice needs to be loud enough to be heard over the societal cacophony.

Maybe once we do that, we can get that squirrel problem under control.