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Us and Them-Ism

Us and ThemAnd after all we're only ordinary men

The wanna-be congressman appeared with his neat hair and pressed suit, a competent yet compassionate expression on his face.  "The first thing I am going to do when I get to congress is to work to repeal Obamacare," he said, expression growing subtly angry.  "I will do everything I can to give you back the care you need from those who think big government is the solution to every problem."

My wife grabbed my arm, restraining me from throwing the nearest object at the television.  I cursed under my breath.

No, it's not my liberal ideology that made me react this way; I've had a similar reaction to ads by democrats who demonize republicans as uncaring religious zealots who want corporations to run society.  I am a "flaming moderate," which means that I get to sneer at the lunacy on both sides of the political aisle. I grew up surrounded by conservative ideas, and probably still lean a bit more that direction than to the left, but my direction has been away from there to a comfortable place in the middle.

It's not the ideology that bugs me, it's the use of the "us and them" approach to problem solving.  If only we could get rid of the bad people, we could make everything work.  If only those people weren't oppressing us.  If only those people weren't so lazy.  It's the radical religious people who are the problem.  It's the liberal atheists.  It's the corporations.  It's the government.  All of this makes the problem into something that isn't the fault of the person making the accusation, conveniently taking the heat off of them for coming up with solutions to the problems.

Taken to its logical end, the "us and them" mentality leads to concentration camps, the Spanish inquisition, the gulag, or McCarthyism.  The problems this state of mind creates are much bigger than the ones it is trying to avoid in the first place.  Hate crimes are committed against people who aren't like us, while others are demonized for voicing an opinion that go against the "right" way of thinking.  Both of these reactions are extreme, and both of them push us further from the solutions to any problem.

Us and them-ism is also a prominent feature in medicine.  Drug companies are evil, Medicaid patients are scum, doctors are too busy counting their money to care, and patients don't listen to what their caring doctors say.  My conservative patients come in to the office assuming that all of the problems in health care are obviously caused by Obama, just as the liberals blamed it all on Bush four years ago.  They worry about me leaving medicine because of the passage of the ACA, not really knowing what kind of impact it actually has on primary care physicians.  Ironically, the one thing both conservatives and liberals agree on is term limits for congress members, as we all see that the "bad" special interest groups are controlling congress.  Maybe that's more of the us and them-ism, but I can get anyone to laugh at a joke with a congressman at the butt.

"When you don't have blood going to your head," I explain, "you pass out so the blood can get to your brain easier.  Getting blood to your brain (and your heart) is pretty much essential...unless you are a member of congress, where having a brain or a heart seems to be a liability."  I've gotten laughs from the right and the left on that one.

We unfortunately are soon to experience the pinnacle of us and them-ism: a presidential election.  Those who govern us leave governance and embrace pure politics. If Obamacare was the best possible law, the republicans would demonize it anyway to avoid giving the president the political upper hand.  The same would happen if there was a republican president; this is bipartisan power lust with no apology.

Yet the problem in my exam rooms remains: care is too expensive, there is more red-tape and less good care, more patients have no insurance than ever before, and doctors are getting really, really tired of dealing with this mess.  Patients die due to poor access to care (far more than most people realize), and many grow rich off of a system which pays more attention to shareholders of device manufacturers than to the patients with the devices in their bodies.

The intersection between health care and politics is the place where I lose my temper.  Politicians playing the power game with the lives of my patients are my arch nemesis.  This is insane.  This has to change.

When I was a medical student I did a cardiology rotation.  I had a patient who had a heart attack and was sent to the floor, seemingly stable.  I met her and her family, getting to know the situation as well as could be understood by a student.  I heard the overhead page for the code on the ward she was in, so I ran to see if it was her who had suddenly crashed.  My heart sank when I came to her room and saw a flurry of activity around her doorway, with her family somberly standing outside while people hurried in and out of the room.  Her husband's eyes were tearful as I came up to the doorway.

"It's Maria," he said to me, "She just stopped breathing."

I gave a weak smile to try to comfort him. "I'll go and find out how she's doing."

She wasn't doing well.  Her heart rhythm was nothing I had ever seen before and her face was ashen.  The respiratory therapist was assisting her breathing using a bag-mask and the nurses were attending to her IV.  The cardiology fellows I was working with on the rotation were in a corner, far away from the woman, arguing with each other.

"I think it's a junctional rhythm with PVC's," said one with passion.

"No, it's clearly a left bundle with a-fib," argued another, with derision in his voice.

As the argument went on between the doctors, the woman grew more pale.  She was obviously dying.  I thought about her husband, not able to be with his wife as she lay dying in bed, away from him, instead being the subject of an academic debate about heart rhythms.

I felt sick.

The rhetoric on health care seems eerily similar.  The patient is laying on the bed dying while the politicians are vying for the upper hand in the debate.  The patients are ignored, though, serving as a tool with which to smear the other side.  Just like I felt when I was a medical student, I feel powerless to do anything while a tragedy unfolds before my eyes.

With, without And who'll deny that's what the fightings all about Get out of the way, it's a busy day And I've got things on my mind For want of the price of tea and a slice The old man died




"I want you to get me a new doctor," she told me, a bit of disgust coming out in the sharp tone in her voice.

"What happened?" I asked.

"He asked me if I was nauseated, and I told him no, I was just vomiting.  Then he asked if I was feeling pain in my stomach, and again I told him no, it was just vomiting.  He then told his nurse to write down nausea and abdominal pain.  When I objected, he just gave me a bad expression and walked out of the room."

I tried to come up with a plausible explanation for his action, but there was none.  "I'm sorry," I said.  "There are a lot of people who come back from him feeling really happy and listened-to.  It's obvious that you saw none of that from him."

"I asked his nurses if he aways acted this way," she continued, "and they just shrugged and told me that he sometimes did."

"I'm happy to send you to a different doctor," I said, shaking my head.

I hate it when this happens.

I send people to specialists for two main reasons:

  • I am not qualified to offer the treatment or procedures the specialist can give.
  • The specialist has far more experience with the problem, and so can offer better care.

But there is one thing I am not doing: giving over care of the patient.  Patients are more than just diseases or problems to be solved.  Patients are more than a single organ system.  It is my job as a PCP to orchestrate and oversee the care my patients get as a whole, including those areas also managed by other physicians.  I am, in essence, borrowing the specialist for their experience and skill to help me take care of my patient.

So when I have a patient come back from an encounter like this one, it not only bothers me for the sake of the patient, I feel a personal sense of being let down by the other doctor.  I need help, and the person I chose to help my patient didn't do the job I need them to do.  Were they just too lazy to listen?  Were they just having a bad day?  Do they understand the question I was asking them to answer?  Did the patient somehow come across in the wrong way?

I am never quite sure for the reasons for these bad experiences, but I hate playing specialist roulette every time I send people to another doctor.  It's not only a waste of time and money, it also undermines the person's trust in me for choosing the specialist, and often hurts their overall view of my profession.  Why bother going to the doctor and pay lots of money only to be patronized, trivialized, or simply ignored, while not seeing their problems get better?

I get the same sinking feeling when I send a patient to the ER.  When I have a person come to the office with problems that need immediate attention, it is often quickest to send them to the emergency room, where they can get labs, x-rays, and specialty consults in a very short period of time.  There are times when I call the ER physician to explain my rationale for sending the patient - especially when I think the reason my not be apparent to someone seeing them for the first time - but there are other times when it is glaringly obvious to me what's going on and what needs to be done.  Yet, again it feels like a game of roulette, never knowing if the doctor will see what I see and do the proper workup, or if the patient will call the next day saying nothing was done in the ER.

From my perspective, the big problem is one of information.  I am working with much more information than the other doctors.  I've often seen the person for many years and in many circumstances, knowing how significant it is when this particular person comes to my office complaining of pain.  I actually had a physician come to me with an acute appendicitis, and even my staff knew how serious a problem it must be for a physician to want to be seen immediately.  I also have all of the previous workup on a problem, a history of previous problems, and I know the family, home, and psychological landscape in which the person lives.  When the person goes to the specialist, the other doctor has only what I send them and what the patient tells them.  What seems obvious to me may not be the same for someone seeing them without my information.  But I do expect them to consider not only the patient's motivation for wanting to be seen, but my motivation for sending them.

It comes down to a single thing: respect.  Patients deserve to be treated with respect, and I am angry when my patients get otherwise.  Beyond that, I deserve to be respected by my colleague for having put thought into my decision to ask for help.  The visit my patient described was not just insulting to her, it was insulting to me. I try to give other doctors the benefit of the doubt, as sometimes personalities don't work together, and everyone has moments where they drop the ball.  Encounters like this one before go into my database when I decide who I will ask when my patients need more than I can offer.  My lack of consults to certain providers, especially after I had been using them in the past, should send a message to them about my opinion of their care.  I've had several physicians ask me why I wasn't sending them as many consults as I was doing previously.  My universal answer is this: my patients had bad experiences at your office.

They are my patients, and I expect them to be treated well.





"Your system is perfectly designed to yield the outcome you are presently getting."  - Not sure who said it, but dang, were they smart.

A patient was recently recounting some of her bad experiences with her health care.  I shot back with some of my frustrations with this system that seems hell-bent on making me give worse care to my patients.  We both paused and shook our heads.

"It's a mess," she said.

At first I agreed with this simple assessment.  The system that is not a system is disjointed, disorganized, dysfunctional, and frequently makes me dyspeptic.  It seems like a bunch of disparate groups each fighting for its own place at the front of the money line, with patients suffering for this chaotic thing we call a system.  But the cynical, conspiracy theory wielding part of me buried deep within my people-pleasing primary care mind suddenly grabbed control.

"No, it's not a mess," I said, getting a surprised expression from my patient.  "It's malignant."

Her surprise turned to curiosity, and she tilted her head, urging me to expound on this idea.

"The problems we've got are not problems that exist simply because of a lack of organization; there are people, institutions, and corporations that make lots and lots of money because of that chaos.  There are forces out there who want the system to stay just like it is.  There are lots of people who would lose their jobs, and companies that would go out of business if health care became efficient.  That seeming chaos," I concluded, "is job security for an awful lot of people.  I don't think it's accidental that things are the way they are."

She nodded at me as I got up to close the visit.  Conversations like this can get me really far behind in my schedule, so I had to stop while there was still a chance.

"Is there anything that can be done about that?"  she asked as she walked into the hallway.

I shrugged.  "I am sure there is, but I also think any effort at doing so will be met with very stiff resistance.  People may want the system to change, but it's too big of a cash-cow to go down easily - regardless of what the politicians say."


There is something about the word I used: malignant, that seems a perfect adjective for the American health care system.  A malignant tumor is a group of a person's cells that no longer acts in the interest of the whole body, putting its own growth as top priority.  The body possibly can handle a single malignant growth, like a single skin cancer, but when the cancer becomes widespread it is a threat to the survival of the body.  The tumor's desire for it's own growth eventually causes its own death, as it kills off the body it once was part of.

Our system has multiple metastases that feed off of the money meant to fund care for people's health.  These consuming entities will, if left untreated, kill the system entirely.  They don't want to kill off the system that feeds them, but they can't see beyond their own profits or political agendas.  Taken individually, they may not bring down the system; but as the overall burden of malignancy grows, the true purpose of the system - caring for patients' health - becomes increasingly difficult, if not impossible.

I know this sounds harsh, but the reality I've seen growing before me over the past 18 years in the exam room is becoming increasingly dire.  People are dying from our system.  Others see this, but offer solutions aimed at the external symptoms instead of facing the cancer that will take all of us down eventually.

The cancer?  The hospitals, lawyers, politicians, drug companies, lobbyists, insurance companies, device manufacturers, and yes, the doctors who continue to plunder a system that is struggling to keep standing.  There are huge profits in ordering unnecessary tests, doing unnecessary procedures, admitting people who should stay home, making a payment system that is intentionally incomprehensible, and paying politicians to see only a small part of the story.

So what's the solution?  Do we expose the bad people who make money?  Do we get corporations to stop wanting to make a profit?  It's far more complicated than just pointing at greed and getting on a pious pulpit pretending that we would do differently.  If we've left the meat out in our back yard, we can't blame hungry wolves for coming and eating it.  If our system keeps holding out fists full of cash, we are foolish to act surprised that there are people willing to take it.


Just as chemotherapy is the horrible price to pay for a cell gone rogue, the cure for our system may seem worse than the problems.  It will be a bitter political pill to swallow for anyone brave enough to take it.  The sad fact about health care reform is this: lots of people will lose their jobs, and lots of companies will go bankrupt.  There are far too many companies dependent on a system willing to waste money.  There are far too many jobs that exist because of a payment system that is mind-bogglingly complex.  There are far too few people in the position to start the cure who are willing to face the firestorm that will follow.

It's going to be hard, folks.  Hospitals will close, people will lose their homes, and the political voices will become increasingly shrill.  I truly doubt that we as a country will have the courage to stick out the long, hard therapy we need to survive.  Can we really become efficient and conscientious if those good qualities bring ruin on an entire industry built on inefficient and haphazard care?

If we don't, the malignancy will kill us - both figuratively and literally.



Our Broken System Part 7: Plumbers, Ninjas, and Doctors

When my wife told me about her encounter with the plumber, all I could think was: "What a jerk!"  Then I was hit with an eerie sense of familiarity.  OK, it wasn't exactly eerie, but there was some creepy music in the background.


We had a shower fixed about a year ago, costing us a bunch of money.  I would do it myself, but past experience gave me frightening images of water dripping through the ceiling, and bathrooms falling in to the middle of our garage.  I still awake with cold sweats from previous plumbing experiences.  So we found a plumber with good recommendations on Angie's List, so we thought we were safe.  But after paying a whole lot of money, we were left with a faucet that seemed like it was made out of a plastic-metal alloy and took about half a turn to get any cold water.  We were afraid to call the guy back, however, given how much he charged us for our previous encounter.  Despite the cheap faucet, we had no leaks and experienced no sudden appearances of bathrooms in our garage.

Then last week my daughter told us  the shower wouldn't turn off.  Through the fine art of faucet jiggling I was able to get the shower to stop (and she was quite impressed by my mad skills).  But another night's shower had the same complaint from my daughter, and my skills were not as mad as I was.  Since it had been about a year since our last repair, and since the faucet seemed chintzy, we called back the same plumber and he came over to assess the damage.  It seemed like it was his fault.

The plumber, being the trained craftsman he was, quickly found the source of the problem: us.

My wife explained what happened, as well as the elbow pain we all experience turning the cold water, and he shook his head.  He noticed the caulking around the cold water faucet was missing, and told my wife that someone had "obviously" done something to that faucet.  When my wife explained that my mortal fear of plumbing (and her mortal fear of my plumbing) made this an impossibility, he looked at her with a condescending skepticism.  It seemed "obvious" to him that either my wife was not telling the truth, or that a plumbing ninja had infiltrated our bathroom to remove the caulk without our knowledge.

Things got worse when my wife suggested that the hardware installed wasn't very high quality.  He seemed offended at the suggestion that he would use anything but the best.  How could a mere mortal non-plumber suggest that the shower that she uses every single day is anything but the best?  Her suggestion that it shouldn't take so much turning to get cold water was clearly a statement of ignorance, or a fabrication designed to slander this highly trained professional.

The good news was that it was just the white cartridge thingy that needed replacement and so it took only $75 to get rid of this jerk and get our shower back to its previous sorry state.  I suspect that because the faucets have so much play in them, my daughter cranked them harder than she should to turn them off and so damaged the cartridge thingy.  Either that, or the plumbing ninja was at doing more than going after the caulking.  I shouldn't think about it too hard, though, because I've actually created leaks in pipes by prolonged contemplation.


Unfortunately, this encounter with the demigod of plumbing reminds me a lot of what my patients get when they see certain specialists.  Several aspects of my wife's experience are eerily similar (there goes that music again):

  1. The plumber's reality trumped anything my wife experienced.  Despite the fact that she showers in it every day, she was not given any credit for her own experience.  The plumber's self-centered view of the universe made it impossible to consider my wife may know something about the shower.  In the same way, patients are treated like they simply can't be having the symptoms they are having because it doesn't make sense to the highly-trained and extremely intelligent doctor specialist.
  2. My wife's suggestion that the plumber may be wrong was something she was made to feel guilty about.  It's not just that she was wrong in her reality experience; she should feel shame for experiencing anything the plumber said wasn't true.  This is exactly the same as my patients who visit doctors with the same reality-distortion field.  They are bad people for experiencing what they do.
  3. Our experience with the plumber makes us want to avoid further encounters with members of the profession, and to seek alternatives if possible.  Why is it such a mystery that patients seek alternative medicine when they are made to feel stupid when they go to the doctor?  Nobody wants to be made to feel guilty for symptoms they don't want in the first place.
  4. We feel like our ignorance (and mortal fear) of plumbing is an opportunity this guy used to pass cheap material off on us for a premium price.  My patients come back from specialist, ER, or hospital visits with enormous bills and often feeling they are not listened to.

I don't mean to pick on specialists, as there are plenty of primary care docs who treat patients in the same condescending way.  Our profession has a bad reputation that we've been working hard to earn, so I have to share the credit with doctors of all kinds.  I have patients actually tell me that I am "the first doctor who has ever listened to me."  While I think that is an exaggeration, the perception is rampant: we docs are arrogant know-it-alls who charge too much.

So what next?  I am going to Angie's List and am going to write a bad review of our experience with this guy.  I owe it to other plumb-o-phobes so they can steer clear of this doink.  I can't do this without hearing the shrill cries of doctors detesting their patients who give them bad online reviews.  How can I complain about this guy?  What do I know about plumbing?  I should just be glad I don't have a shower in my garage!

We need to wise up.  Some of this arrogance stems from a system which turns patients into E/M and ICD-9 codes, forcing doctors to pay more attention to documentation requirements and achieving "meaningful use" than to what the patient says.  Doctors are sick and tired of the system, and sometimes facing a patient who blames us for the system that makes our lives hell gets under our skin.  But nothing excuses arrogant reality-distortion fields like this plumber and many docs emit.

Nobody wants to see a jerk.




The following post was one of my most read and commented-on from my old blog.  I wrote it in June of 2008 after seeing a patient who was utterly ashamed of his obesity.  I was so struck by his self-loathing that I wrote the post within a few hours of seeing him.   My most recent post on defectiveness brings back a lot of those emotions, and I thought it would be an appropriate time to re-publish that post. ----

I saw a gentleman in my office for his sciatica.  He was having severe pain radiating from his lower back, down to his calf.

I was about to describe my plan to him when he interrupted me saying, "I know, Doc, I am overweight.  I know that this would just get better if I lost the weight."  He hung his head down as he spoke and fought off tears.

He was clearly morbidly obese, so in one sense he was right on; his health would be much better if he would lose the pounds.  On the other hand, I don't know of any studies that say obesity is a risk factor to ruptured vertebral discs.  Besides, he was in significant pain, and a lecture about his weight was not in my agenda.  I wanted to make sure he did not need surgery, and make him stop hurting.

This whole episode really bothered me.  He was so used to being lectured about his obesity that he wanted to get to the guilt trip before I brought it to him.  He was living in shame.  Everything was due to his obesity, and his obesity was due to his lack of self-control and poor character.  After all, losing weight is as simple as exercise and dietary restraint, right?

Perhaps I am too easy on people, but I don't like to lecture people on things they already know.  I don't like to say the obvious: "You need to lose weight."  Obese people are rarely under the impression that it is perfectly fine that they are overweight.  They rarely are surprised to hear a person saying that their weight is at the root of many of their problems.  Obese people are the new pariahs in our culture; it used to be smokers, but now it is the overweight.

The fear/disdain of obesity has reached into areas where it should not be.  I regularly have to tell mothers of chubby babies that it is perfectly fine for their child to be that way.  Children under three generally regulate their eating to what they need.  I do not believe a baby can become obese on breast milk or formula.  Now, if they are giving the child french fries and burgers, that is a different matter.

Instead of patronizing obese patients with a lecture, I try sympathizing with them.  Just because something is simple doesn't make it easy.  How do you quit smoking?  You just stop smoking.  We should just pull out of Iraq.  There should be peace in the middle east.  People should stop hurting each other and start being nice.  All of these are good ideas, but the devil is in the details.  Losing weight is a struggle, and it really helps to have people giving you a hand rather than knocking you down.

Don't get me wrong, I don't deny the health risk of obesity.  I do my best to work on weight loss with my patients.  But the idea that their personal worth lies on their BMI is extremely damaging.  There are a lot of screwed-up skinny people out there; just look at super-models.  It is a lot easier to lose weight when you actually like yourself and want to do something about your health.  Our culture of accusation and shame simply makes obese people hate themselves.  If you hate yourself, why should you want to take care of your body?

Is obesity a problem?  Sure it is.  But we need to get off of our self-righteous pulpits.  Obese people should not be made into a group of outcasts.  The "them" mentality and the finger-wagging are no more than insecure people trying to feel better by putting down others.

It sounds a lot like Junior High.

If we really want to help with obesity, we need to grow up.

See the old blog post for some very interesting comments.



Our Broken System #5: Riding Dinosaurs

I guess I am no longer "old school."

In medical school I was repeatedly told of the importance the face-to-face encounter with patients, and how we avoid it at our peril.  The physical exam, I was told, is neglected by the younger physicians in lieu of scans and studies.  This, I was told, was a universally bad thing.  Medicine had to be done face-to-face, with attention given to the examination.  All other care is, to some extent, a cop-out.

I think this is a bunch of donkey dung. Patient face-to-face is overrated and overdone.

I know: my readers are probably asking themselves, What?  Dr. Rob is downplaying the importance of face-to-face encounters with patients?  This is the doctor who delights in the exam room?  This is the doctor who loves personal interaction?  Who is the impostor who has infiltrated his blog?  Does he have a lesion in his temporal lobe?  Is he having flash-backs from his years of eating those "funny mushrooms?"

First off, I don't even like mushrooms (too slimy).  Second, the lesion is in the pre-frontal cortex, not the temporal lobe.  Third, it really is me and I mean what I said: patient face-to-face is overrated and overdone.

The foundation of good care is communication and contact, but these two things do not have to be done in person.  After all, you are not with me right now.  As much as I like you folks, I am glad you are not sitting in my den while I am writing this (which is good, because I need a shower).  Communication is not only possible when not done face-to-face, it is often more effective when done that way.  You might get different things out of this post if I spoke it to you in person, but you would also possibly get distracted, not hear things correctly, or forget what I said altogether.  You'd also wish I went ahead and took that shower.

Why is this any different in the exam room?  There is an ignoble reason why I insist on face-to-face encounters with my patients: it's the only way to get paid.  Our system leaves me no choice but to force the patient to take time away from life and sit around in my office waiting for me to spend my short time listening to them.  I do my best to make that time worthwhile for them (and think I do, most of the time), but I really wonder if this is the best way to do things.  No, that's not true: I don't wonder at all.  It is not the best way to do things.

Imagine this:

You or your child gets sick.  Which interaction would you rather have with your doctor:


  • Call the doctor's office, get put on hold or leave a message on voicemail.
  • Get an appointment with someone in the office (probably not your doctor, as their schedule will be full).
  • Take time away from normal life to go sign in at the office, fill out paperwork with information your doctor probably already has, and sit down and wait.
  • At a well-run office, you may end up being there 30-60 minutes total, but many/most offices will make the total visit time much more than that.
  • You finally get back to talk to the doctor (or other provider), and you tell the story of your problem.  Ideally, the doctor has all your previous information correctly in the chart and is up-to-date with all that has happened since you were last there.  This "ideal" is almost never true.  More likely, the doctor asks you about things you assumed he/she already knew about you.  Also, the doctor is probably rushed and distracted, trying to move through this visit as quickly as possible due to the long line of patients waiting after you.
  • You are given advice and/or prescriptions.  You may or may not remember what is said or why the prescription was written, as the doctor is going to be paid the same regardless of the length of time he/she spends explaining things.  Payment is based on how much documentation is put in the chart about the visit, not about how well the visit is done.


  • Send a message to the doctor that you have a problem.  Using a template to guide your questions, along with space for free-text, you give your best explanation of your concern about you or your child.  Alternatively, you record a video of your situation and your complaints that your doctor can view.
  • The doctor responds to your communication either by email, video conference, or phone, asking questions and clarifying the situation.
  • If the situation is obvious (your child is sick with a fever and you just need an excuse for school, or your blood pressure readings are up and you need to increase your dose of medications), your doctor handles this electronically.
  • If there is a need for seeing the doctor in person, 95% of the encounter is already done and documented, leaving only the physical exam to be done in person - something that can be accomplished in a few minutes for the vast majority of visits.

I am sure employers would prefer method B, as employees would spend far less time away from work.  I am also sure that the magazine collection in our office does not offset the hassle of coming in.  I also think that I would possibly give better care doing method B, as I could take more time than just the time I spend with the patient in the exam room to find out what's going on.  I also think my documentation would be easier, as I could use the electronic medium to record what is said while it's being said, rather than relying on my memory and obsessiveness to detail to get things right.  Documentation would be driven by the encounter, not by the need to bill.

Okay.  I confess that I am really running with this thing beyond what I actually believe.  I do value the exam room visit, and would not like care to be all electronic.  I know that some things would be missed that would be picked up in person.  Yet I do wonder about our clinging to the face-to-face paradigm of care being analogous to people who still insist on having newspapers delivered to their house to get information they could have gotten for free and in greater detail on the internet.  Are we riding dinosaurs?  Does our system of payment force us to use a method of interaction that is slow, wastes time, creates confusion and chaos, and yields worse care?


Wouldn't it be amazing if we could figure out a way to facilitate care that actually uses this wondrous thing called the information highway instead of plodding along on the back of a brontosaurus?  If we did, then maybe I would have time to spend with my patients who actually need to see me face-to-face.




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.