Rural ERs

A woeful lack of specialty and trauma care outside of the city. The reasons are obvious:

The reality also is, as we have stated here, that specialty surgeons (and trauma surgeons in particular) are in short supply. Besides that, due to the litigation climate and the demands on their time they would face being the one or two guys in town that do trauma, they absolutely do not want to practice in rural areas. Sometimes the best they can do outside a trauma center will not keep them out of court. Result? They leave for the big city. Go figure.

Comments

Anonymous
I wonder if the time will ever come when the patient populace will finally get fed up with this abandonment. Not likely, though, they have usually come back with a “thank you, may I have another please” after being smacked in the face by the providers.
Anonymous
It doesn’t matter who or how many people you train… nobody wants to go to the middle of nowhere to work their butts off alone without anyone to help.
Anonymous
“Abandonment”???
What planet do you live on where YOUR needs mean a surgeon has to be enslaved to a place he doesn’t wish to live or to practice under circumstances which are inadequate, exhausting and fraught with medico-legal risks?
Mike
I think the next time a lawyer refuses a case, they should be sued for “abandonment”. And the next time an insurance com pany refuses to insure for water damage or car liability, they should be sued for abandonment. Because apparently, according to the brilliant scribe above, a physician is required to 1)work for free at all times and 2)must work in a place whether he/she wants to or not. So why just doctors? Lets do it for everyone. Lets make cops move from one city to another. Or public defenders.
Moronic.
Anonymous
How do doctors know the “litigation climate” of places they’ve never been?
Newsflash: Rural areas lack lots of things cities have because they lack lots of people. It’s not that surprising that expensive surgeons are one of those things. It doesn’t mean that physicians need more money, liability immunity, or anything else.
Anonymous
For there to be abandonement there has to be a mutual contract that both parties enter.
Anonymous
3:07 PM needs to sue his brain, it seems to have abandoned him.
Anonymous
It is about the level of tripe that one normally expects from the provider first mentality crowd such as 11:34 pm that is indicative of the problems that this country really faces.
Mike,
Anytime that the providers wish to man up and step up to the plate to be treated like everybody else, they can get their colleagues together and undo all of the provider first entitlements that have been enacted since 1910. Until then, they can either hold up their profession’s “do no harm” and gallant egalitarianism claims or be called out as members of the hypocritical profession that they are a part of. I think that everyone here knows that patients are not worth anything more than $$$ to the providers and will be readily abandoned at the drop of the hat.
Anonymous
People always mention “doctor entitlements/legislation.” What the heck are they talking about? Could someone point me in the right direction?
Anonymous
Anon 9:40, erstwhile “Criminallopath” thinks any refusal to provide service is “abandonment.” It hardly matters, since his opinions are wacky fringe mutterings anyway, pretty far from what are considered reasonable thinking. That his mind boils with perceptions of a vast century-long conspiracy mapped out by the Flexner Report is just evidence of similar paranoid thinking (the last Czar was still breathing!). If any of it were true, where is the public outcry against such supposed market manipulation? Could it be that the public actually wants some form of standards for physicians? Maybe having some evidence of education and training that can be verified by testing and having met minimum standards for length of training is seen by less troubled folks as reasonable. Still, it’s refreshing to know the East Bay is still capable of homegrown looniness.
Anonymous
If there was not enough practice activity to sustain a specialist in a particular community, and that specialist leaves to practice where there is more community support and demand for that specialty, is that abandonment? Sounds like a functioning economy to me. But maybe we don’t want medical care to behave by those rules. Maybe magical thinking would be better.
Anonymous
Talk about tripe 9:40
You can’t “abandon” someone you were never involved with in the first place. Get a clue why don’t ya. What’s your problem anyway, do you feel insulted ’cause a doctor suggested you may need antidepressants?
Anonymous
If exposing the hypocrisy of the allopaths is considered “…wacky fringe mutterings…” for those with a vested interest in maintaining their current oligopoly position and if characterizing the goring of their sacred cow in such a manner helps them sleep better at night then so be it. Many more today are aware of the nefarious scam of Flexner and even the most minimally motivated with even the most minimal understanding of economics can easily figure out for themselves that what I am saying is correct. The force of Flexner is just as strong today as it was at the time of its implementation. Can you cite a single provision that has been repealed? I don’t think you can unless you make something up.
The current “sham” about standards is just that. Purported standards are only used to restrict entry into the field. I can see why the existing providers are afraid to let the boards and the residency serve as the determinant for practice. It is patently apparent that many of those currently rejected secondary to the supply side limitation constricture at the medical school level would be able to get through medical school with a “C” average and pass the boards and complete a residency. Gone would be the days in which providers are paid exorbitant sums solely because of their market position. Providers would actually have to be competent in a system in which there is competition if they wished to stay in business.
Existing providers, however, need not worry about standards. They can malpractice at will and only the most egregious of cases have to worry about losing their license to practice. Otherwise, we see the equivalent of kangaroo court justice from boards packed with cronies of the providers.
As far as the “east bay” comment. Given the nebulous attribution of the person or people that it is being directed to, you have an out. If, of course, it was directed at me then it is incorrect and fits well with illogical pabulum of the rest of your post.
Okulus
So Anon 1:36, if not those trained in the particular field of their expertise–what you refer to as a “sham”–what exactly do you propose as an alternative? I for one would like to know that a particular professional, say a medical doctor, has expertise established by the testimony of someone besides himself. If the statement of a medical school dean, a university chancellor, a residency director and the committee of examiners for a particular practice specialty is insufficient to satisfy, then just what will satisfy?
How would you do better?
The “market”–if you can call it that–that preceeded Flexner was a minefield for the sick and hopeful: traps of charlatans, patent medicine and device vendors, diploma mills and hucksters. You make it seem as if Flexner hijacked the American medical education system. (Did he do the same in Europe, as they have also rationalized their training systems similarly?) The more rational assessment would be to say he established standards that were much more rational, open and uniform than those that preceded them (though far from perfect, as racial and ethnic discrimination persisted despite his reforms). If his reform was so reprehensible, why are there so few voices suggesting how (as you have yet to show?) I suggest to you their durability indicates their fundamental reasonableness.
As for your idea of “supply-side restrictions”, I fail to see how opening the doors of newer or larger medical school classes to “C”-students serves anyone’s interest except the overly absracted armchair thinker. More graduates don’t make for more postgraduate training opportunities that generate competent and adequately-experienced practitioners. That requires populations of
patients, concentrations within academic medical centers and a sufficient diversity of pathology to make for a sufficient training experience. Your suggestion that we make “barefoot doctors” out of heretofore unqualified applicants fails in it most fundamental sense. They might be graduates, but who will want them?
Anonymous
Oh, I’m sure Criminallopath will be the very first one to line his family up to be card for by the “barefoot doctors.”
Anonymous
Why do people keep ignoring the fact that there are two established training pathways for what is regarded as full medical practice rights in the USA…..MD and DO.
By definition, there is no monopoly.
Add to that the expansion of practice rights for nurses, naturopaths, chiropractors, optometrists, dentists, posiatrists, the whole argument for monopoly is rather silly, to put it mildly.
Anonymous
Okulus:
The Flexner model is based, in part, on the antecedent German medical education model of the time. In looking at Flexner, there were two groups of suggestions made. The first deals with the nature of the education required. I find it to be a bit much with the “basic sciences” emphasis to be a bit drawn out. The curriculum is something that can be tweaked but should stay relatively intact. The second deals with restricting supply. Closing over half of the existing schools at the time, coupling schools to large research institutions, precluding for profit schools, etc. are all for the sole purpose of restricting supply. If it were up to me, I would remove all of the supply limiting portions and let the weeding out occur via the USMLE and the residency process. If the USMLE is worth anything when it comes to weeding out the incompetents then there should be no complaint against this. Foreign schools that do not follow one, some, many or all of the supply side restricting tenets of Flexner produce graduates that can and do pass the USMLEs (while being held to a higher standard than their domestic counterparts) thereby showing the fallacy of the overtly restrictive nature of the supply side restriction segments of Flexner.
For any new schools opening that don’t meet current CME guidelines but that can obtain regional accreditation, I would suggest following the California legal model. License to practice in their state of training but without comity to obtain licensure in other states.
The current system places the restriction on those that can enter medical school. Once in, a C average (pass) is sufficient to make it through. Once licensed, any discussions of “quality” go out the door as it is virtually impossible to remove licensure from even the most derelict of providers. The level of “quality” that is tolerated from the licensed providers is not commensurate with the level of purported quality demanded of students applying for entry into the domestic medical schools.
I would rather see a system based on the free market when it comes to providers. Those, that through their skill, excel should be compensated to the degree that the market will bear. Those that do not should not. Under the current system, the most hack of quacks is guaranteed a high after expense compensation rate and it has nothing to do with his/her skills but instead has everything to do with a marketplace in which supply is restricted.
Anonymous
Revoking medical licensure from “bad” doctors will never happen. The legal lobby will see to that.
Anonymous
Crim,
With all your hyperbole about Flexner and your rants about patient abandonment, let’s ask you the real question – if you were a trauma doc in a rural area, on call every or every other night, with no life to speak of, wouldn’t YOU want to leave and go elsewhere? Or would your beneficent and altruistic spirit keep you in the boondocks?
Anonymous
I would do exactly what the providers are doing now: Extort the patient populace, threaten them with abandonment and demand that I be payed a princely sum for lording over them. I would also demand special legal rights and privileges available to no other field of endeavor. Just like with the existing providers of today, I would recruit the captive populace to fight by proxy to help enrich me even further and to shield me from liability. After that I would take the Ferrari (one of three) for a spin.
Anonymous
Crim,
Your sarcasm – not – aside, you didn’t answer the question I posed – would you leave a rural area if you were the sole or second trauma surgeon? And think before you pontificate with your clueless sarcasm – rural areas can’t afford to pay “princely” sums, no one else besides your delusional mind thinks that doctors lord it over others, and no one is extorting the patient population no matter what you may think. Answer the question – would you stay or go? Leave the sarcasm out of your answer.
Anonymous
I did answer the question, though the answer, like, you did not. I would do exactly as the existing providers are doing now. I would eschew any and all of this “do no harm” nonsense or “gallant egalitarianism” nonsense. The rural populace, after all, are only potential patients. I would use my market position to demand special legal rights and privileges while demanding hundreds of thousands of dollars per year in compensation. If the populace did not comply, I would abandon them and practice somewhere else.
The current system will not change until there is a fundamental realignment towards neutrality in the supply-demand equation. Until then, the providers hold the proverbial cards.
Anonymous
No Crim, you didn’t answer the question – it was simple, unlike your verbose meanderings and rants about providers “special privileges”. Lord, what horse manure you write. So, again, I ask – would you stay in a rural area as the only trauma surgeon in town, having no life and being poorly reimbursed, if at all? A simple answer will suffice.
Anonymous
Are you purposefully being obtuse or does it just appear that such is the case? What aspect of my response did you not understand? Let me know and I will clarify it for you.
Anonymous
Just answer the question with a simple yes or no – talk about being obtuse..