To those who have read Atlas Shrugged, this would make sense. To the rest of you, I recommend strongly that you read Atlas Shrugged.

I agree with the earlier post that stated that we should worry about the future, for ourselves and our families, even in cities.

In the past, there wasn’t so much of an issue. You went into a field, and you took care of the patients, no matter the disruption to your lifestyle. It’s just how it was done.

I don’t think that that lifestyle will cut it today. I’m the first to admit that, although I enjoy my busy rural ED practice, I don’t want to be there 24/7, and I want my time off. While I may sometimes (often?) question the standards to which some of my colleagues adhere (last night I talked to my general surgeon about a [well-insured] 50 year old with appendicitis, at 8 pm; the direction was “admit to my partner so he can take it out in 11 hours), I understand there have to be boundaries.

I agree about the Reductio. Money is tight, and money isn’t enough to motivate people to take care of every patient who really needs care, in a hospital’s referral network or not. In order for physicians to be truly happy in our profession, we need the respect and appreciation of the public. We also need the money, but the fact that many of us make a lot of money (and made more a couple of decades ago) didn’t help with this sort of appreciation.

It’s like drug policy: regulate everything, and you have millions in prison for minor violations, at massive expense. The problem is just getting bigger. The medicine version is: pay physicians less, regulate them more, and then complain that some of them might not want to take call.

Eliminate the entitlements and the rules.

Anon 2:01

NOT to the ENT doctor who reasonably chooses to limit the number of days he is available….

NOT to the University ENT doctor who chooses to limit the number of patients he takes on…..

But it DOES apply to a private out-of-area ENT in a non-referral hospital who chooses to limit the number of hospitals he covers?

Correct me if I misunderstand the facts as above. The ENT is in some community setting and has arrangements to cover certain hsopitals, but no other.

You can limit the number of days you’re on, the number of patients you have, but not the geographic area you cover? If someone from New Mexico wanted to send the patient to South Carolina, would it be an EMTALA violation if the South Carolina doc declined the transfer?

For those who think that’s a reductio ad absurdem, I’d say EMTALA is a reductio ad absurdem. It’s reach extends day by day. They’d extend it to my private office if they could, and I’m sure they’re trying.

I think the immediate answer is to do what you did, keep trying until the child gets while they need, but without wasting energy being judgmental about those who wouldn’t help. Without wearing their shoes, you can’t know if they were stretched beyond their resources and saying the right thing in saying “no” or just plain greedy. Since you can’t know, why bother thinking about it.

When I tried to say yes to all, life was unbearable and I broke eventually. People, including a few ER docs, took flagrant advantage of my willingness to help. “Broke” means that I hurt bad enough to reassess my values, shrug off the sense of responsibility for anyone who I didn’t already have a doctor patient relationship, and set up barriers to all of the other unmet needs out there, just opening the valve a little when I had the time and energy to provide good treatment to my standards.

That naturally means I don’t take ER coverage anymore.

But keep in mind, that I didn’t work in 12 or 24 hour shifts, but took call 24 hours a day for weeks at a time. There were no “turn-off” times.

On the other hand, when I got all of my barriers in place to unmanageable demands (perhaps perfectly manageable to someone made of tougher stuff–but I didn’t make myself so why should I feel guilty) I found myself enforcing my rules to not take on a child, who I probably couldn’t have helped but perhaps have given a small measure of comfort. When it was too late, I realized that I didn’t feel comfortable with that and feel guilty about that.

So now I feel free to make the rules that I need to make to have my life livable, and make it a rule to break them when my conscience compells me to do so.

But it is my conscience that must compel me, not your bind, so that doesn’t solve your problem. Perhaps accepting that everyone is trying to survive this profession in their own way (some by unbridled greed) and respecting that, even if it means that they are unavailable to help you with your patients might help you be more at peace with it.

We all accepted certain frustrations when we entered our chosen profession–although judging from the blogs, I don’t see much evidence of the acceptance part. One of the burdens you accepted by going into ER medicine was putting yourself in the peculiar position of always having to find someone to hand patients downstream to and doing this many times a day. This puts you in the position of being especially impacted by service limitations–such as one or no ENT docs who are actually obligated to be available to your patients–especially upon choosing to work in a semi-rural hospital.

Letting yourself resent that is a bit like a family physician resenting always having his skills compared to specialists, or a psychiatrist resenting his patients being nuts, or a physiatrist resenting dealing with chronic pain patients. Surely you knew it would be so?

I am all for it. it is freaking scary that the country is running after Hilary, Barack, and other politicians in just exactly the opposite direction.

I, too, believe in capitalism. The more that health care is “centrally planned”, the worse the outcome. Our current health care system responds to economic realities. To see the effects, I just have to look at what hospitals and physicians are doing, and what they are not doing. They are doing redo CABGs on 90 year-olds. They aren’t as interested in filling cavities in kids. One pays, the other doesn’t (for the most part).

While I did feel a sense of national shame when I watched “Sicko” (I brace for the boos), I think that the better solution is truly market-based, and revolutionary.

1. Get rid of all of the entitlement programs, the federal insurers, and by extension most of the private insurers. Vastly reduce taxes to the minimum needed to run a federal government (probably less than 20% of the current budget, if that), and ensure meaningful oversight: by physicians and interested citizens, at the local level. Overhaul tort law at the national level.

2. Charge cash for everything. Post prices. This means that if you have a lot of money and are seeking care for your cancer, you can shop around at the best places, and get your care where the outcomes are the same, but the price is right. Prices settle to the “right” level, and when the working poor or indigent person is looking for the same care, they will know what it costs. What would that mean in the ER? Maybe it costs $150 for me to look at your ear and treat your pain from otitis. When an indigent person comes for care, the hospital will decide, based on its mission and values, how much care to provide, in partnership with local institutions. That includes how much it will cost to subsidize my time “being there” for that patient.

3. Let individuals, foundations, churches, etc., decide how to care for those who can’t afford care. The boards who run these local organizations have a better idea of the need and worthiness of individuals seeking care. Keep government out. While I give to charity, I also pay a LOT of taxes. Eliminate a lot of the tax, and unburden the organizations who want to provide care from the myriad regulations that make this difficult and attach strings, and I would believe my charitable giving was on target.

4. Get rid of HIPAA, EMTALA, and all of that. Let local hospitals decide the rules of staff membership, and local communities can decide whether the decisions the hospitals make are in keeping with the values of the community. By extension, open up the medical record to “open source” development, so the most useful and pertinent information is there, in the best possible format (depending on your specialty – in the ER, the screen would show allergies, meds, and major medical problems first). Everyone has a medical ID number, and facilities can track patients by this number, to decrease diversion and abuse of narcotics–and get these individuals to appropriate treatment. Voila! Billions in red tape are gone, and the information is better. Can you imagine the medical record for a patient with a URI? “Patient has three days of cough and rhinorrhea. Normal exam. URI. Supportive care, instructions given.”

Stringently criminalize the misuse of medical information. If you log on to someone’s chart who is not your patient, on purpose, it’s a crime. If you log on and you’re not a physician or authorized to access records, it’s a crime.

There would be a shake-up as the market tried to determine what services actually cost, but overall I think it would be a lot less than what we charge right now. I also think that practicing in this environment would be much more rewarding. You can choose to do charitable care, instead of having it pressed upon you. You can work at a tertiary care center because you want to take care of the sick kid with the peritonsilar abscess, and teach your residents how to do the same.

If you want to “semi-retire” and see patient on a limited basis in a rural clinic, you can do it. Right now, malpractice premiums prevent this.

I imagine this post will be regarded as wildly naive as well. But if you don’t imagine the solution, you’ll never get there.

Unrealistic? In the current setting, yes. But compared to the current system, with HillaryCare grafted onto it? You decide.

I am waiting for the good constructive ideas.

I see it the other way around. Refusal to see a patient like this did not cause malpractice litigation to get out of hand, it is the RESULT of malpractice litigation getting out of hand. As I recall, you had tort reform pass in 2005. Let’s see if it survives challenge.

Tort reform failed in my state. A story like yours gets far less sympathy locally.