Kevin, M.D. - Medical Weblog

Many very elderly and terminal patients are all too happy to cut down on "maintenance medicines" that are no longer relevant or appropriate. This does take some discussion, and there's the rub. These conversations take a lot of time, and time is money. Very few of us have the time to discuss the pros and cons of PSA testing, so we just order the test for all men over 50 to be safe. Lawyers bill for their time, so they can take all the time they want to discuss issues completely and document them fully. Doctors get paid by the encounter, so an encounter prolonged by a complicated discussion and extensive documentation loses money. It's that simple. We have to pay our bills too.
 

"When is a patient too ill or old for medicine"

After the age of 85 or after $100,000 in lifetime medicare expenditures no more trips to the ER or hospital should be allowed.

When I am old, immobile, and with declining mental capacities my will states not to even treat my UTI or pneumonia. Just a few days and it will all blissfully be over.
 

$100,000.00 In lifetime payments? I'm happy your so lucky that you don't seem to have much clue as to the price of a single hospitalization, surgery or price of medications. Wouldn't be many people living a whole lot of years if everyone has a 100,000.00 lifetime limit!
 

What are you guys bitching about...just keep treating and testing for everything forever regardless of age...this is what we get paid to do and it protects us from liability...no one ever got sued for diagnosing prostate cancer in a 96 year-old...

Have you ever heard of a mechanic refusing to repair a car because it is too old? This isn't your parents we're talking about...
 

I agree. You treat until the patient or the family want to stop.
 

I also agree and that's how I practice in the ER. Assume everyone is a full code, even if they come in rigor mortis. Patient has no brain, ie they herniated due to a head bleed? Easy, call neurosurgery for a VP shunt. A person's not dead until the family/health care proxy agrees they are dead.
 

Doctors get paid by the encounter?? How come those billing sheets have different boxes to check for the length of the visit -- short, intermediate, etc.?
 

I get paid by the month. Absolutely no incentive to do anything....except cover my white ass.
 

What kind of incentive would it take to make you act like a professional, instead of someone just punching a card until they can afford to retire? Why don't you just give the patients a checklist when they come in the door and not make them waste their time on you since you're not really providing them what they are paying for - professional conduct and advice based on your training and knowledge?

And you wonder why patients don't respect you.
 

I'd much rather have them get a full body CT and $2000 woth of labs while they're in the waiting room. Of course, you can tell what kind of doc I am by what I write on a blog at 11 o'clock at night after a 12 hour workday when I'm overtired and grumpy. I don't know why we have board ceritification, they should just let you sit on the toilet and read how people blog and you can decide that way who's a good doctor.
 

"$100,000.00 In lifetime payments? I'm happy your so lucky that you don't seem to have much clue as to the price of a single hospitalization, surgery or price of medications. Wouldn't be many people living a whole lot of years if everyone has a 100,000.00 lifetime limit!"

Yeah, thats right. If you want more then pay for it yourself. The medicare dollars don't grow on trees. It actually comes from some working taxpayer. Medicare can't remain viable if people keep taking out far more than they ever paid into the system.
 

Why do you always assume that the people you are talking to isn't worthy of your almighty standards? Do you not know that almost all people on medicare have spent all their life working and paying for medicare that other people used?

Its the way the system works. You work 30-40 years, pay into medicare, someone else uses what you pay and then one day you retire. Should we all be euthanized now on retirement day? Would that please you?

Besides the absolute truth is. YOU are the ones using up all the medicare dollars. DEFENSIVE MEDICINE= useless tests for unsuspecting people=robbing of medicare dollars=insurance fraud.

Tell it like it is, k?
 

k,


You seem quite selfish, thinking only about the moment and not how a program can be sustainable doing the most good for the most people. You can work fo 50 years, and considering inflation, still not even come close to what is being spent on individual futile medicine because family "wants everything done"

OK what is a reasonable amount you are allowed to consume? a million dollars? a billion? What if you could be kept alive with a trillion dollars in expeditures at the expense of basic care for everyone else in the future. Would that be fair?

People don't like to grapple with things that are too hard to grapple with. But a line and limits have to be drawn somewhere. I am trying to get you to think a little bigger than just yourself.

You have not been paying attention to this blog. We practice defensive medicine not because we want to, but because that is the path the system has forced us down. That is also what people seem to want. I have agonizing discussions daily with family "who want everything done". People can't seem to accept that at 90 years old you start getting weak and that eventually you die. half of all medical expenditures are spent in the last 6 months of life. 1% of people consume 70% of the healthcare dollar. That is unbalanced.
 

"We practice defensive medicine not because we want to, but because that is the path the system has forced us down."

I hardly think all physicians want you as their spokesperson.
 

A lot of it, IMO, is our culture. Not just the entitlement mentality but the attitude that there should be zero risk and no one should be allowed to die. Until people get their heads out of the sand, I don't see how physicians have much choice but to practice defensively.

I'm still on the right side of 50 but I figure I've had a good run. I don't want aggressive tx or screening; spare me the misery and use the $ for someone else. Trying to convince my doctor of this has not been easy, unfortunately. I think he's in the grip of the Dark Forces.
 

We practice defensive medicine not because we want to, but because that is the path the system has forced us down."

"I hardly think all physicians want you as their spokesperson."

OK, lets see if any physicians will speak up and disagree
 

Just keep practicing defense, save up, and get out when you can...the day I take medicolegal advice from some old retired person on Medicare is the day hell freezes over...
 

Careful there, honeybunz! Some day you too will be old and on Medicare and dishing out all kinds of free advice to those whippersnapper physicians.

Just remember free advice is worth what you pay for it. ;)
 

yeah...nothing!
 

"OK, lets see if any physicians will speak up and disagree"

This problem is so widespread and rampant. For example, I saw an 18 year old last night witha headache and right hand numbness. Do 19 year olds have strokes? Yes, maybe one in a million in a normal host. But I made the neurologist come in at 4 am and see the patient "just in case". What do you think the neurologist did? Laugh at me, tell me i'm too defensive? No, she admitted the patient, and ordered an MRI on top of the CT I did. There is no Downside to ordering expensive tests and wasting money, there is only downside for errors of ommission. The longer I do this, the more defensive I get. It's worked so far for me; knock wood.
 

mri of the brain, cspine, or both?
sounds like cervical radiculitis, but you got to cover yourself...
Plus the neurologist gets paid every day she writes a note on an inpatient...not to mention it will take days to actualy get an mri done...

Way to practice defense...
 

"There is no downside to ordering expensive tests and wasting money"

Do you not see how you speak out of both sides of your mouths?

You call patients selfish for using medicare dollars and talk about how you want us to see the "bigger" picture of down the road. But, then you talk CYA, all the way!

For some reason that sounds a lot like only thinking about yourself, and not having the good of all mankind any where close to being on your mind or in your agenda. Why are you so self-important that you want to drain all the medicare dollars? Particularly, why do you do it and then try and pass the blame for your behavior on to yoru patients? I wonder why there hasn't been some study done, by shrinks, on how Drs. lack of financial consideration is effecting American healthcare? Or why they find a need to misdirect the blame.
 

CYA because we have to, not because we want to. I think about the herd but for me personally it is the survaval of the fittest, and the fittest wont be cavalier. The system doesn't provide for error of omission and does not reward us for saving money. The rules need to be changed for a better result for the herd.
 

I'll try to spell it our for you since you seem a little dens:

litigious patients --> need to order cya tests ---> bring the whole system down --> screw litigious patients.
 

anon 6:09...LMAO...We have come to expect this type response from you...Thanks for the laughs you give me!
 

I'm not anon 609 pm, but I laugh when I read these blogs about "the greater good" and not ordering tests for the betterment of mankind. Have we seen a single physician decry our CYA profession "for the betterment of mankind"? The system is SO FAR DETACHED from this idea is why these statements are so laughable. I actually often go home after a shift and think of a CYA test I forgot to order and have to call the ER and have the patient return to the hospital for even MORE TESTING. I don't do this to spite anyone, I'm not trying to bring down the system, this is just the mentality WE ALL HAVE in the ER, it's so ingrained in our mentality I would have to actually relearn medicine if tort reform occurred. Again, I'm not insulting anyone, I'm just presenting the realities of our system.
 

I've never seen a group of people so unwilling to take responsibility for their actions as these last several commentators.

But hey, I guess not every physician can be a good one. Someone has to be in the bottom of the curve.
 

"But hey, I guess not every physician can be a good one. Someone has to be in the bottom of the curve. "

You are incorrigible. When will you get it? All physicians (that is, all physicians in higher risk specialties) practice some form of defensive medicine. My best friend was valedictorian of my medical school class, he practices defensive medicine (actually, he tries his best to avoid patients completely, but all academics have to be "on service" for one month). It's one thing to "take responsibility for their actions". It's another to risk your career by taking chances and not ordering defensive tests in a country which places blame for bad outcomes square on the shoulders of those who are supposed to help the sick.
 

chill out man! Why are you letting some old guy sitting at home rile you up? He's just an old ingrate with a bad knee that has some kind of grudge against the physicians that are inexplicably keeping him alive...

You're an MD! Act like it...now go practice some more defense!
 

Some of the nurses think I'm nuts.. I've been walking into the ER chanting "Deefense....Dee-fense" lately.
 

The nurses are RIGHT!
 

dont' advertise your defense...just do defense but pretend that it is medically necessary...
 

DOn't you do this?: I always tell the patients "I really don't hink you have (insert disease here), actually the odds are less than One percent, but I think you need (insert defensive test here) 'just in case"
 

And you wonder why medicine is a business, not a "profession" anymore.

It's because profit is all that motivates most of the anonymous'.
 

Why do you think all of the anon's from patients are just from one person? I'am the "old ingrate" with a bad knee but I'am NOT the majority of anon posts here. I can't claim the one you just accused me of. My posts was a long time ago. It must have really tripped your trigger,I'm glad it did.

I basically like Physicians, I have what I perceive as some of the best there is. But,I contented then and still do today that anyone who has ever went through knee replacement, two weeks post-op is too soon to discontinue pain meds. You can't remark on that because you obviously haven't had one.

Also, you most likely don't have a clue as to what is involved with having one. PT is necessary but hard. Imagine your knee bending at 75 degrees and you are working around a 9inch incision, a fresh one, and someone is forcing your knee back to 95 degrees. I had therapists telling me to insist my Doc. give me pains meds to get through therapy, and a family Doc who was outraged over ever increasing BP because of lack of pain control. My OS was 68 years old and had seemed to have lost his human compassion. So what? It happens. Get over it, I did.

BTW, I've never sued anyone in my life (Dr. or otherwise) so get off my ass.