Archive for the ‘Guest Posts’ Category

My Secret Addiction

Wednesday, April 3rd, 2013

By an Anonymous Emergency Physician

Hi. I’m Anon. I’m a 44 year old emergency physician. And I’m an addict.

My addiction came to light when my Press Ganey scores plummeted after I started to stand up to the chronic pain and frequent ER patients.
The fact that I have an addiction was reaffirmed when I went to my state’s Prescription Drug Abuse Summit. When I saw so many professionals from varying fields (medicine, law enforcement, pharmacy, education, etc…) assembled, I realized my problem: I’m addicted to prescribing pain medications.
As with any addiction, the first step in treatment requires acknowledgement of the problem.

I thought back to how my addiction began.
Coming out of medical school, there is a certain power that comes on the first day of residency. You suddenly have the power of the pen. You can write prescriptions for low blood pressure, high blood pressure, low blood sugar, high blood sugar, too many bowel movements, not enough bowel movements.  The list goes on and on. But one of the largest ways in which we can help patients is by treating their pain. Controlled substances. Yes, the new physician quickly learns that the pen wields an awesome power and an awesome responsibility. This feeling fades quickly in the face of an 80+ hour work week.

Fast forward 5-10 years. You are seeing 10-12 patients at the same time, all the chest trauma goes across town, and you have a waiting room that is 20 patients deep, and you already know the medical history of ten patients waiting to be seen on the tracking board. Hospital administrators pressure you to make sure that all nonemergent patients are treated and released within 90 minutes. All admits must be up to the floors within 240 minutes … if only the medicine consultant would get down and actually see the patient.
It’s not uncommon to see 40 or more patients in a shift. I make it a point to look up the prescription/controlled substance database our state has. This has been an absolute lifesaver to me and to several patients I have confronted.
The problem is that it takes time:
– 2 minutes to look up the patient and print off the list
– Another minute to count up the number of prescriptions (it does take time to count to 50 or even 72 – my personal best record for one year)
– Another 3-5 minutes to go to the room and confront a patient who has an issue
– Then a few more minutes to sit down and document the conversation.

So I have 10 minutes to evaluate a patient, create notes in an arcane electronic medical record, and discharge the patient. Yet all of that time can be taken up by doing what is right with drug seeking patients. I cherish the ability to “catch” someone who is diverting drugs, to be able to sit down with them and have that “aha” moment. I have even had a few patients come back and thank me for confronting them. But my worth is partially measured by the number of patients I see per hour. My worth is also partially measured by my patient satisfaction scores. It’s not all possible.

Why do I and so many other physicians have this addiction? NOT providing the prescription is very hard. It takes time to do the research on the patient. Confronting the patient with a problem is emotionally draining. Doing it 5-10 times in one shift is not only a reality, it is downright crippling. It sucks out last bit of energy out of your soul. Rather than confronting patients and arguing, it’s far easier to write a prescription for narcotics and move on to the next patient. This is the mindset of thousands of physicians. Healthcare is different than it was 5-10 years ago.

As soon as I started saying “no” to drug-seeking patients, it was as if I had been liberated. I still have lapses and give out prescriptions to a patient against my better judgement. And I occasionally get burned. I am human and some days I just don’t have the energy to argue and fight with drug seeking patients. As time passes, however, saying “no” gets easier.

Physicians need to start saying “no” once in a while. Take the time to review a patient’s medication history. Don’t be the doctor who prescribes the patient’s 300th Norco tablet of the week. Saying “no” just once a day can be liberating. Try it just once a day for a month. Then twice a day. It gets easier. At first, I actually felt guilty when I wrote for Ultram instead of Vicodin. It has become easier with time.

Physicians can’t fight this addiction alone, though. We need the backing of hospital administrators. Hospital administrators must listen to physicians and see how much of a toll the prescription drug abuse epidemic is taking on patients, the healthcare system, physicians, and the bottom line. How many $500 ER visits will a hospital be willing to write off when they learn the patient just wants 20 Vicodin? Hospitals must stand behind and support physicians who are willing to stand up to drug-seeking patients. Perhaps patient satisfaction scores will take a hit. So be it. Administrators need to take a step back and see the big picture on this one.

Maybe administrators need to be held legally liable for patient overdose deaths when they haven’t created a policy for dealing with medication prescriptions. Sometimes getting sued is the only thing that makes administrators wake up.

So, I’m out of the closet. I am a recovering “controlled substance prescribing addict.”

It feels good to be free of that burden.

Well … most of the time at least.

It Didn’t Feel Like A “Win”

Saturday, February 16th, 2013

By Birdstrike M.D.


My kid and I are outside in the front yard blowing bubbles, enjoying the blue skies and 70 degree weather when she says, “Cool Daddy! Look, there’s a police car coming down the street. Oh, cool! I think he’s coming to see us!”

Uh, oh, I think to myself. Despite my kid’s excitement, I know that rarely does anything good come delivered by a policeman. My wife is inside, my one kid is with me and my other is inside, so they’re not coming to give me some tragic news. Or are they? My parents….my siblings….is everyone okay? Why is a sheriff pulling into my driveway?

I exhale for a minute. Maybe it’s Jim, the officer that lives in the neighborhood, I think to myself. He’s probably just stopping by to chat or say, “Hi.” As the car rolls closer, squinting to look beyond the window glare I see that it’s not Jim. It’s an officer I’ve never seen before. Clearly none of us has done anything to get arrested….

“Daddy! I wanna go see inside the police car! Daddy, will he give us a ride? Ooh, ooh, can I see his gun? Cool!” says my kid, jumping up and down with excitement.

“Let’s see what he wants,” I answer.

The driver door opens. A huge officer gets out, in grey uniform, bulletproof vest bulging underneath, with black wrap-around sunglasses, and a toothpick in his mouth.

“Are you Dr. Bird?” he asks, as serious as a heart attack.

“Yes, sir,” I answer.

“I got a present for ya,” he says, as he pulls a thick rolled up stack of paper from under his arm and hands it to me.  “Here’s your subpoena,” he says.

“My what?” I stammer. “What’s this all about?”

“You’re getting….” he starts before,

“Daddy! Daddy! I wanna ride in the police car. I wanna see the lights go on! Yay!” says my little one.

“…sued,” I finish the sentence for him.

“Yes, sir. You and every other doctor in this county it seems like. I’ve got about a dozen more to go serve. These lawyers are unbelievable. (laugh) I happen to know this one will sue you for breathin’ and win, too. You know, the one on the back of the yellow pages? You ever run into any trouble, though, you call him. Trust me, he got me out of a jam one time,” he says with another grunt-laugh.

“Wow. Thanks for that wonderful advice. You’ve really brightened my day,” I snark back at this guy, who apparently thinks it’s hilarious to be part-time process server and part-time comedian.

“Oh, don’t take it personally. It’s just business,” he says chuckling, as he spits out the same old lie and cliché I’ve heard a thousand times from doctors who’ve been sued.

“That’s great. Thanks. Anything else I can do for you today, officer?” I ask, dejected.

“Oh, yeah, I’m gonna have to give you a ticket for parking your car on the street overnight….Just kidding!” he says, and give’s a snort-laugh.

This guy’s unbelievable, I think to myself as I turn to walk away.

“Don’t worry, Doc. You’ll win that case. That lawyer will sue a dead dog if he could get it to settle for a bone and a biscuit,” he says.

“Uh, thanks for your…uh, support,” I say, shaking my head in disbelief.

Yep, it happened. After about 30,000 lawsuit-free patient encounters I finally got hit with a lawsuit. I guess 29,999 out of 30,000 isn’t bad, I think to myself. What’s that, 99.99% accurate? Well, it’s still not perfect; still not 100%.

I walked inside and ripped through the pages and start reading about the case of which I have zero recollection. What? This? This is nothing. This is ridiculous, I think to myself. Where’s the malpractice? Where the h—l did I not do everything as I was taught, as I should have and as I would do again?

I can’t find the malpractice, because it’s not there.

Almost every day in my training, it was either implied to me, or I was explicitly told that someday, no matter how perfectly I practiced, no matter whether I met or exceeded the standard of care, that I would be falsely accused of malpractice someday and be sued. In each of those teaching moments, I was told how to practice so as to decrease the chances of such a false accusation and how to document, so as to be able to fight the inevitable false accusation in court. Never once was I told, or was it implied that it wouldn’t happen.

Though these words were never spoken, the unspoken lesson was: You are getting excellent training. You are going to be an excellent doctor. You will be prepared to handle any situation thrown at you. You will go out into the real world and do your best with every patient you see, and one day you will be sued for it, and possibly put on trial. I trained at a top notch institution. My teachers were right.

Over the next week, I obsessed about the case. Over and over and over again, it ran through my head, what would I have done different? I can think of all kinds of things I could have done differently, but none of them seemed better, or even equally as appropriate as what I did. In my head I kept hearing the mantras of physicians that have walked the plank of false medical malpractice allegations before me, “It’s the cost of doing business,” “It’s not about you, it’s about money,” “It’s not personal,” “Every doctor gets sued.” Yeah, bulls—t, I thought to myself. The more I thought about it the more it infuriated me.

Also, reading through the record, I couldn’t help but think, of all the patients I’ve seen, why this one? There’s nothing here, nothing at all. Not only did I not commit malpractice, I cannot see where any of the other providers even might have or possibly committed malpractice.

As the months went on, I went through the “process.” I met with my lawyer. I reviewed the record ad nauseum. I read every bit of literature about this case I could find. The more I read, the more I was certain I did nothing wrong. The more I thought about it, the more I realized that didn’t matter. Also, the more I was told and the more I told myself it “wasn’t personal” and “was just the cost of doing business” the more I took it personally. It is personal. When you dedicate your life to helping people, often times without payment, often times at 3 a.m. dog tired, on your kids birthday or your third holiday in a row, and it’s routine business that you’ll be extorted for money just for doing your job and doing it well, you’re damn right it’s personal.

Along came the depositions. The plaintiff deposed their “expert” who plainly put, was not an expert. He was a hired gun, paid thousands of easy dollars, to testify that everything I and my co-defendants did was absolutely wrong. Also, he was of a completely different specialty than my own. His testimony was laughable. His answers seemed to indicate he hadn’t even read the evidence closely or at all. Regardless of how bogus his testimony was, my attorney tells me, he made enough (false) accusations to get the case to trial.

One by one, our experts line up drooling to testify that their expert was absolutely wrong. They had the truth on their side and they were actual experts. But would the jury understand? Whose “experts” would they believe? As strong as my case was, I resigned myself to the fact that that’s what the case would come down to. Not what was right, or what was wrong, but whom the jury chose to believe, for whatever reason they chose to believe him. As difficult as it can be to judge another physician in a different specialty I can only imagine how difficult of a task it is for a jury with no medical background to judge the decision making process of a physician, in a complex medical case. How many times have you gone to an M&M conference and a dozen experts argue over a case with a bad outcome and even those highly trained experts couldn’t agree on what the “standard of care is” let alone whether or not it was met?

Over months, the trial draws closer. My tension waxes and wanes, fades and returns with each deposition, each email from my attorney and with any patient encounter that reminds me of the case. Ultimately as the trial closes in on me, the tension builds. All the while, I know I met…No, I exceeded the standard of care. As the trial date gets closer, the more I realize how little that may matter. How would I come across to a jury? I’ve never been on trial. I know I’ll be very nervous on the stand. Will that be seen as appearing “guilty” or will the jury understand and see my side of things?

I get an email from my lawyer. “Just to let you know, the trial is set for –/–/—-. There will be a routine mediation meeting tomorrow. You do not need to attend. We are taking this to trial. You did nothing wrong. We will fight this every step of the way.” Deep breathe, exhale.

The next day, breaking the silence comes a “ding.” It’s an email on my phone. I open the inbox, and I see two words that shock me:


“The charges against you have been dropped. No money will be paid on your behalf. There will be no trial. Congratulations. You are dismissed with prejudice”

I could hear and feel the air start to leak out of the balloon of pressure hanging over my head: “Dismissed with prejudice.” I ask my lawyer to translate: that means “Over. Permanently. Done. You are innocent. You won.”

Well, it didn’t feel like a “win,” but it was over.  I was relieved not to have to roll the dice.  Even though I was vindicated, there was no “win” in being falsely accused of committing malpractice considering all the time spent reviewing charts, attending legal meetings and depositions, and all the mental stress and sleepless nights.  Others have said that although a dropped lawsuit is a win in a literal sense, it is a great loss for patients and doctors because it drives a harmful and dangerous wedge in the physician/patient relationship.  As I progressed forward from this point on, I truly understood how true this is. I couldn’t help but feel that from then on, memories of this lawsuit and the process would be irreversibly intertwined with each patient interaction, each handshake, each differential diagnosis and treatment plan, as much if not more than the science, pathophysiology and the text books I read.



This author does not divulge protected patient information or information from real life court cases.  Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients.  To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that it should be considered fictional.  Any opinions expressed here are of the author alone and not those of epmontly, WhiteCoat, my employer or any of the hospitals with which I am affiliated.

Comic Relief

Tuesday, January 22nd, 2013

Another cartoon courtesy of Mednificent Comics.
The answer to the question at the end … “absolutely”


That’s Some Serious Constipation

Monday, December 31st, 2012

By Birdstrike M.D.


“Help.  Help!  I need something for the pain!” I hear a woman wailing from Emergency Department room 4.

“What’s that all about?” I ask Veronica the nurse.  “I guess I need to see that one first, don’t I?”

“No.  She says she’s got constipation and no other problems.  You need to see room 7 first, which is a 70-year-old male with back pain, hypertension and a family history of abdominal aneurysm.  He might have an actual emergency,” answers Veronica.

“Definitely, and thanks for letting me know,” I say, as I walk in to see the possible abdominal aortic aneurysm (AAA) patient.  I glance at his vital signs.  They are totally normal.  I walk in the room and he’s sitting on the stretcher eating a triple cheeseburger, smiling and says, “What’s up doc?”

“What brings you in here today, Sir?” I ask.

“Oh, nothin’.  My back hurts.  I think I pulled a muscle,” he says.

“Have you ever been told you have an abdominal aneurysm?”  I ask.

Out of room 4 and into my ears, blast some more primordial screams, “Oh.  Oh!  Ooooooohhh!

“No, I’ve never had one, but my dad died of an aneurysm.  I’ve got high blood pressure, though.  You better go see that lady, doc,” he says.  “I’ll be fine.  You go check on her.”

“Let me feel your abdomen,” I say.  I can’t feel any pulsating mass.  I push a little deeper: still nothing.  I feel his radial, femoral and foot pulses: they are all normal.  I finish my exam and put in an order for a CT aortogram,  along with the rest of his workup.  “Sir, I need you to put the cheeseburger down, until we get this checked out, okay?  We need to keep your stomach as empty as possible until we know what’s going on, alright?”

“You got it, doc,” he answers.

I move on to room 4.  “Oh.  Oh!  Heeeeeelp!   I need a laxative.  Please, something for the pain,” screams an obese 42 year-old Caucasian woman.

“That should be no problem.  Just tell me a bit more about what’s going on, ma’am,” I ask as she paces the room, obviously very uncomfortable and anxious out of proportion to a case of constipation.

“It’s been about a week since I had a bowel movement.  I feel  r e a l l y  bloated,” she says.  “Whoa.  Whoa!  Whoa!”  she moans, then takes a few slow, deep breaths.  “It feels like I’ve got an 8 pound ROCK stuck down there binding me up.  Please!  Give me a laxative, an enema or something.  Stick your hand up there and take it out, I don’t care what you’ve go to do.  Just do something for the pain.  I’m begging you, please!”

“Where is your pain?” I ask her.

“Right here,” she says pointing to her lower mid abdomen.

“When was your last menstrual period?” I ask.

“Oh, geez.  Oh geez!” she says, as she stops pacing and lies down on the stretcher.  She lies on her side and gets into a fetal position.  “Just give me an enema.  I’ve been disimpacted before.  Just do it.  Do it!”

“Okay, I’ll have to do a rectal exam.  If there is an impaction, I’ll try to remove as much as possible and then we will give you an enema.  It will be very uncomfortable, but you’ll get tremendous relief.  Okay?”  Veronica hands me some gloves and some lubricant.  I lean over to do the rectal exam and she lets out her loudest scream yet.

“I think it’s coming out!  Arrrrrrrrrrrrrrrrrrgggggghhhh!” she screams.  I lean over again to do the rectal exam and out comes a very,





Huh? Veronica and I quickly turn to each other; our eyes lock together, bulging in disbelief.  “A baby?! What the…?” both Veronica and I ask in unison.  “You didn’t tell us you’re pregnant!”  we both say, in stereo.  This woman is not constipated, she having a baby!  Not only is she having a baby, she having it in my 8-bed “almost” ER where I only work once per month, where I’m the only doctor on duty, and with no Obstetrician or  Labor and Delivery unit.

“What?  Pregnant?!  I’m not pregnant!” says our “constipated” patient.

Just then, I realize that it’s been years since I’ve delivered a baby.  The head is out and the baby already managed to take a breath and emit a loud wail between contractions.  Oh crap! I think to myself.  “Call 911 for transfer, get an OB kit, and hook up some oxygen tubing, while I deliver this baby.”  Please, let this be a quick, easy delivery where I just catch, I think to myself.

Aaeerrrrrrrgggh!” she screams as I hold the baby’s head and then deliver the shoulders.  With only a second or third push, out comes a screaming “8-pound-rock” of a baby boy.  We clamp and cut the cord, wrap the pink, screaming, wiggling baby in a blanket and hand mom the new unexpected addition to her family.  The complete lack of prenatal care didn’t seem to hold this kid back, I think to myself, as he’s as vigorous and healthy appearing as I’ve ever seen a newborn baby.

Our new mom holds her baby and begins to cry.  “I’m 42 years old.  They told me I could never get pregnant.  He’s my miracle baby.  I didn’t even know I was pregnant,” she says, still in disbelief, sobbing.

“Neither did we,” I say, breathing a momentary sigh of relief.  “Where’s the ambulance?  We need to get mom and baby to Labor and Delivery.”

Suddenly, I realize I have a possible AAA patient in Room 7.  Hopefully he’s still stable, I think to myself, not having expected to have to play Obstetrician while he was getting a CT scan for possible leaking AAA.  I glance into his room and he’s sitting up, chomping down not on his cheeseburger, but a super-sized order of fries and a 32 oz. Coke.  This guy isn’t sick, I think to myself.  I check his CT report and the rest of his tests.  Everything is completely normal.

“I have good news, Sir.  All of your tests are normal.  There is no evidence of aneurysm.  You probably did pull a muscle in your back.  I’m going to let you go home now,” I tell the 70-year-old man with “back pain”.

“Doc, I know it’s none of my business, but I was in the waiting room with that woman, and she was screaming and carrying on about being constipated,” he replies.  “I must say, I thought she was being a bit over dramatic, but I saw one person go in that room and two come out.  I got to give it to her, that’s some serious constipation!”



This author does not divulge protected patient information or information from real life court cases.  Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients.  To the extent that any post is inspired by the real life experiences of the author or any other physician, all names, dates, ages, sexes, locations, diagnoses, events and all other factual information are routinely changed to the extent that they should be considered fictional.  Any opinions expressed here are of the author alone and not those of epmonthly, WhiteCoat, my employer or any of the hospitals with which I am affiliated.

A Physician Tries to Make Sense of Sandy Hook

Tuesday, December 18th, 2012

By Birdstrike M.D.


Since the massacre of innocent school children and those that gave their lives educating and trying to protect them this past Friday at Newtown Connecticut’s Sandy Hook Elementary School, I’ve struggled to make sense of this calamity as much as much as anyone.  As a Physician who has worked to save the lives of sick and injured children, and as a father of children the same age as those massacred in cold blood, I have searched for answers to the questions, “Why?”   “How do we make sure this never happens again?” and “How do I know this won’t happen to my family?”  along with everyone else.  As I’ve read, seen and listened to various explanations and solutions, some better than others, most have rung very hollow.  The arguments and blame fly back and forth, “We need to ban guns,” “We need more guns,” “We need more outpatient mental health treatment,” “We need to re-institutionalize the mentally ill,” and so on.  The more I listen, the less I am convinced that anyone I’ve heard, from the checkout clerk at my local grocery store, to the President of the United States has any real solution to prevent this from happening again, or even make such happenings less frequent.

As I dropped my daughter off at school today, and let her get out of the car and walk away from me and out of my sight, I realized that to a certain extent, this was and always has been an act of faith of sorts.  As I’ve thought more and more about this horrible incident, the questions keep coming, but without answers.  I have no good answers to the above questions.  In a nearly post-spiritual world where technology can do practically everything but find answers to the truly important questions in life, I realize there is a word that does perfectly describe this incident, and consolidates all the pain, hurt, chaos, insanity, confusion, murder, blood and tears.  All religion, preaching, atheism, agnosticism and separation of church-and-state arguments aside, the only word I can find that offers any sort of explanation, summary or satisfying consolidation of what we saw last Friday is…..evil.

Pure evil.

If anyone doubts the existence of true evil, you’ve seen it.  That is the most disturbing and frightening thing about the incident at Newtown’s Sandy Hook Elementary School.  Despite all the good in this world and all the good we may try to achieve with varying levels of success as physicians trying to heal sick and injured children, or trying to protect our own children, we share this world with a certain element of pure unadulterated evil.  Despite all of our necessary efforts to prevent, protect against and deter it, when someone chooses to truly commit an act of pure evil, they can.  When one does so, there is very little any of us can do about it but hurt, mourn the lost, support the living and move forward with acts of good hoping time will offer at the very least, some solace and clarity.  My deepest condolences go out to the victims of this incident, their families and all of those touched in any way.

Accepting Our New Normal and Finding New Opportunities

Friday, November 23rd, 2012

by Birdstrike M.D.

It Is Here To Stay

The 2012 Presidential election is over. Obamacare is the law of the land and is certain to remain so.  There was tremendous uncertainty not knowing whether the law would be repealed, revised or remain.  Many of us opposed the bill, and there certainly are negatives.  Like it or not, it is time to “get over it,” and not a second later than now.  The new-found certainty offers an opportunity to reassess and adapt to the coming changes.

In addition to Obamacare, other pillars of our “new normal” include patient satisfaction surveys, threats of reimbursement cuts, increasing pressure from administrators obsessing over “metrics,” more time drained by cumbersome electronic health records, resentment from patients who blame us for the failings of the healthcare system, as well as a steady stream of frivolous lawsuits with no end in sight.  It’s time to adapt to our “new normal.”

Comparing and Contrasting With Other Industries

In this modern age of Medicine, these factors have been piled on top of the traditional responsibilities of physicians such as life and death, health and wellness, and paradoxically have seemed to rise above them in importance like unstoppable flood waters drowning the ghosts of Hippocrates, Osler and Marcus Welby M.D.  This contributes to poor morale among physicians and understandably so.  Other industries have had to deal with the same concepts for decades, however.  The service industries are bound by “patient satisfaction” measures and always have been.  Businessmen also have to guard against lawsuits. They expect them and manage the risk and accept it as a norm. I doubt they perceive a lawsuit where they did nothing wrong, as life altering like so many physicians do.  Companies often times have decreases in sales just as our reimbursements may drop and constantly have to adapt.  Just about everyone else in the “real world” has to deal with a “boss” of some variety and a necessary part of their job is to keep that person or entity happy, regardless of whether they like them personally or not.  So why do we find it so difficult to deal with such factors?

Are we special?

Are we different?

In a word, “No.”  Not anymore.  It’s time to accept that fact and move on.  We are now cogs, replaceable de facto employees of a massive business-medico-legal-political machine; nothing more.  All indications are that it will remain this way.  Much can be learned from such other industries that have had to adapt to the stark realities ahead of us.  I think for the profession of Medicine to reinvigorate itself, and for us to truly value what we do have again, we must properly manage expectations.

What Government Will (or Will Not) Do

Though we might each individually be very replaceable, the reality is that we still have extremely high paying jobs in a profession that is relatively recession proof with greatly increasing demand for our services. There are some other positives and ironic realities that I think many physicians are glaringly overlooking.  One is that Obamacare proposes to commit about 1 trillion more dollars towards healthcare over the next 10 years, with tens of millions newly insured.  Necessarily, demand for our services will go up, way up.  And the best (or worst) news is that despite all the talk about “severe rationing” and “draconian reimbursement cuts” there’s good reason to believe that talk is a big load of….nonsense.  That’s right; they’re not going to cut a damn thing.  How can I be so sure?

There has been essentially no real political will, whatsoever, by either political party to make any significant cuts from the federal budget, ever.  Even the most “harsh” and “cruelest” proposals only call for a decrease in the rate-of-increase, of overall spending.  There never has been any, and there’s no reason to predict there ever will be, any policy other than kicking the can down the road until after the next election, and the next one and the next one. The voters have spoken and they want to spend an extra $1,000,000,000,000 on healthcare.  Santa Claus is in fact coming to town!  That may be terrible for the country, but it may well be very good for doctors; that is the smart ones.  There may be more hoops to jump through, more requirements and regulations, as well as creative strategies needed to get a “piece of the pie,” but demand for doctors’ services will necessarily increase, and tremendously so.  Also, despite much posturing, tough talk and threats of showdowns year after year, the SGR-fix has always been passed and the budget debt ceiling has always been raised.  Medicare expenditures will necessarily continue to go up, and up, and up. More patients will be insured wanting our services. The elderly baby-boom population will be sick and growing older and need us desperately.

I was told a story by a retired physician about his long deceased cardiologist father who practiced before Medicare was instituted.  He tells of his father who was a very compassionate physician, but a staunch free-market conservative who like many physicians at the time vehemently opposed the proposed Medicare system.  His father would say that physicians provided charity care for free to the disabled and elderly all the time and that Medicare was just a Trojan-Horse for socialists who wanted to take over the American healthcare system.  He may or may not have been correct, but ultimately to his dismay, Medicare passed and became law.  All of a sudden and very unexpectedly, his salary……doubled.  He never complained about Medicare again.

The point of this anecdote is not to suggest that physicians’ salaries will double as a result of Obamacare.  They will not.  However, it is to suggest that despite the 2000 pages of regulations and requirements in the cloud of Obamacare that hangs over our heads, there will be an unexpected silver lining, somewhere.  I think we can simultaneously work vigorously to reform our profession, yet shed the “culture of victimhood” that has grown like mold upon physician attitudes and search for positive opportunities.

Some Physicians Will “Opt-In”

Such new opportunities will not be the same as in the dead era of Osler, Hippocrates and Marcus Welby M.D.  Also, I cannot say that chugging along with the same old strategy, expectations, and disappointments of a bygone Golden Age will be a winning plan, either.  It may involve simply being content as a cog in a large machine or “system.”  It may involve thriving in the role of “corporate soldier,” learning how to “play the game” while finding ways to save costs, increasing efficiency for your group or other groups and “promoting” your hospital.  Others may move into the government side of healthcare and find opportunities in healthcare policy planning and consulting.  Clearly, knowing “the medicine” isn’t enough anymore and in fact, seems the least important of that which is expected of us.

Other Physicians Will “Opt-Out”

Greater numbers of physicians will find opportunity in opting-out of the system by making their practices cash only, concierge, or declining to participate in Medicare and a more dominant Medicaid system.  Another option may be for more Emergency Physicians and surgeons to exploit technicalities in Obamacare and States with liberal certificate of need laws and open their own centers that offer services for a flat fee outside of traditional government or private insurances.  As more insurance plans require deductibles in the thousands of dollars and refuse to pay for certain services entirely, such centers may gain more traction where they are feasible.

Others may “opt-out” more insidiously.  The new generation of physicians may very well evolve into protocol-following, brown-nosing, corporate mantra-spewing clock-punchers, indistinguishable from other “providers” all while refusing to make the tremendous sacrifices of doctors past, such as incredibly long hours, over-burdensome call schedules with great sacrifice to marriage, family, and personal well-being.  Maybe that’s okay, and maybe that’s what our new Overlords of Healthcare want and will reward.  More primary care physicians and other specialties likely will take the “9-5, no call” route and leave the after-hours hassles to the ED and hospitalists.  More medical students may pick careers in cosmetics over critical care.  More Emergency Physicians may leave high-stress clinical shift work in the Emergency Department for Administration, group management, Hospice and Palliative care fellowships, Urgent Care ownership or anything else seen as less stressful.  More surgeons and specialists may opt out of emergency call for a less stressful life and a focus on elective cases with higher reimbursement to liability ratios.  I see more Anesthesiologist moving to “lifestyle” positions at ASCs doing elective cases, or pain procedures with little or no call.  Many physicians will consider early retirement.

The Silver Lining

The pioneers of Medicine did not have to worry about our “new normal” of Obamacare and all of its 2000 pages of regulations and requirements.  They didn’t have to worry about $300,000 of medical school debt, mega-million dollar frivolous lawsuits or being fired over patient satisfaction surveys based on complaints that may or may not even be valid.  But they also didn’t have our modern-day luxuries, salaries, exploding technologies, or a nation of patients soon to be more widely insured and in demand of our services than ever.  There is much worth fighting to reform, yet even more worth fighting to preserve.  All things considered, we are tremendously better off.

Be sure, Obamacare will change modern medicine, and it will change it mightily.  Also be sure, that with us or without us, and whether we look forward to seize new opportunities or look back upon shattered expectations, the profession of Medicine will be alive and well, and thriving more than ever before.


Homeless Elvis

Monday, October 15th, 2012

By Birdstrike M.D.


I think every Emergency Department has a patient like this.  Homeless Elvis came in to our ED at least once per day, for many years.  Sometimes he’d see each doctor, on each shift in an entire day.  By sheer numbers the amount of uninsured ED visits he accumulated over time was unbelievable.  None of us ever knew his real name, because he never had ID, and he insisted we call him “Elvis.”  His last known job was working as an Elvis impersonator, and due to his uncanny resemblance, this would have been no stretch.  We all knew “Elvis” had no real home, other than possibly our ED.   On one particular day, he surprised us all.

I had taken care of the guy, probably 500 times.  He had an extremely bad heart.  He was told that after a heart bypass, repeat bypass and multiple heart stents, that there was absolutely nothing anyone could do for it.  It was amazing he was even alive.  He would come to the ED, every day with the same complaint: “Chest Pain.”  Sometimes he actually had chest pain, sometimes he didn’t.  Sometimes his chest pain was from a heart attack, sometimes it wasn’t.  More often, Elvis wanted food, clothes, or shelter from the elements and most of all, company.  In our ED, he almost always got it.  He would routinely agree to an aspirin, EKG, and sometimes labs.  Almost never, anymore, would he agree to hospital admission, or stress testing, let alone a heart cath.  He must have politely signed hundreds of “against medical advice” release forms.  He never argued with anyone, made any demands or caused any trouble.  He had been coming to our ED longer than anybody that worked there.  The guy was a fixture of our ED and part of its soul and personality.  Some of us spent more Christmases, New Year’s Eves, and other holidays with Elvis, than with our own families.  I once overheard one of our veteran nurses tell a new employee, “Oh, don’t worry about Elvis.  He’ll grow on you.  Like mold.”

Not surprisingly, Elvis also had depression, in its most severe and chronic form.  Whether his situation led to his depression, or his severe depression rendered him unable to function, it is hard to say.  Rumor had it that he was married with children at one point and that they had left him and that he had lost all contact.  He refused to talk about any of it.  The only thing that helped his mood other than a warm blanket, meal tray and something for his pain was his antidepressant medication.  He had been on it for years.  Nothing else worked.  Sometimes he had a little bit of money to buy it, sometimes he didn’t.  Sometimes he’d get samples, sometimes he didn’t.

I actually liked seeing Elvis as a patient.  I knew him well and I knew exactly how to take care of him, since I had seen him so many times.  Seeing him was, in a strange way, a routine and comforting break during many a chaotic shift.  He was an easy patient, really.  Others got irritated, especially if they were new and didn’t know him well, and especially when the ED was busy.

One shift, we were incredibly busy with 30 or more patients waiting and only two doctors on duty.  The acuity was high.  We had traumas, and we weren’t a trauma center.  We had STEMIs and we had no cath-lab. We were buried.

In comes Elvis by ambulance, with his usual chief complaint of “Chest pain.”  I purposely let my partner Mike see him.  Mike was new to our ED and had just finished residency.  There’s no better time for him to get to know Elvis, I thought to myself.  Doctor Mike signed up to see Elvis and went in to see him.

A couple of hours later I looked in Elvis’ room, expecting to see the usual finished meal tray, tattered boots at the foot of the bed and a lump of a person sleeping with the sheet pulled over his head.  “What happened to Elvis?” I asked Mike.

“He signed out against medical advice a couple of hours ago,” said Mike.  “He completely refused a cardiac workup.  We gave him a bus pass and he asked if he could wait in the waiting room for a couple of hours.  He said he would never come back.”

“Oh, I should have told you about him.  He comes here all the time.  He has horrible, untreatable coronary disease and really, nothing helps him other than an aspirin, some morphine for his pain and maybe refilling his prescriptions.  Cardiology knows him well and agrees.  They’ve said there’s absolutely nothing else to offer him surgically.  They can’t believe he’s still alive.  He’s actually a sad case.  He’s homeless and lonely most of the time.  We’ve tried to set him up with social services, primary care, everything.  He’s just one of these guys that fell through every single crack in the system.  There’s no getting rid of Homeless Elvis.  He’s here to stay.  He’s harmless, really.”

“Oh, really?  I actually feel a little bit bad then.  I told him it’s not appropriate for him to be coming here three times every day for non-emergencies.  I had social work fill a month’s worth of his antidepressant for him, though.”

Interrupting us, somebody yelled from the waiting room, “HELP!  OUT IN THE WAITING ROOM!  SOMEBODY BRING A STRETCHER!  CODE IN THE WAITING ROOM!”

We ran through the double doors to the waiting room.  There was a person lying on the floor, motionless.  “Oh, my God, it’s Elvis!” I exclaimed.  We lifted him onto a stretcher and one of the techs hopped on and started chest compressions as we rolled quickly down the hall to one of our code rooms.  His heart must have finally given out, I thought to myself.  Into “code-mode” we clicked.


Pulse: none.

Monitor: V-tach.

“One, two, three….charging!”

BAM!  We sent a jolt of lightning through Elvis’ heart.


“Look, we’ve got a rhythm.  That was quick.  Check for a pulse,” I said.

“Got one!” said a nurse, as we shot through ACLS protocol.

“Let’s get a 12-lead.  Let’s see this MI,” I ordered.

His EKG was not what I expected.  There was no ST elevation, whatsoever.  There was no MI.  His QRS was wide, really wide, and definitely much greater than 100 ms.  That’s weird, I thought to myself.  “Let’s run a continuous 12 lead.  His ST segments have to go up.”

“Hey doc, check this out,” said one of the techs holding up a pill bottle from Elvis’ pocket.  “It’s empty.”

“Empty?” I asked, “What is it?”

“Am—,  amitri— something.  I don’t know how to say it,” he answered.

“Amitriptyline?” I asked.

“That’s it,” he answered.

He ate the whole bottle?  He overdosed in the waiting room!?  What the….?” I said, shocked.  “We need some Bicarb.  Now, before he arrests again.  Get Doctor Mike in here.”

“Yeah, what’s up?” said Mike.

“Remember Elvis, your patient that signed out AMA about 2 hours ago?” I asked him.

“Yeah, what happened?  Did he have a heart attack in the waiting room, or something?” he asked, shocked.  “Good thing I had him sign out AMA.”

“No, actually he tried to kill himself.  He went into cardiac arrest after taking the whole bottle of amitriptyline you gave him.  We got him back, though.  For the moment, anyway,” I explained.

“You’ve got to be kidding me,” said Mike, shaking his head in disbelief.

Elvis was my last patient of that shift.  I felt like the life was sucked out of me.  I felt like I had coded a family member.  Many times we had kept Elvis alive, whether by providing a meal, treatment for his heart, or simply made his life better by providing pain control or shelter from the elements.  This time we saved his life in dramatic fashion.  I don’t know why, but despite that, I felt that I had failed, and miserably so.  Elvis went off to the ICU alive but in critical condition.  I went out the door and on with my life.

A few days went by and we didn’t hear anything about Elvis.  Then someone said he got transferred to the local University Hospital.  A few weeks later we called trying to find out what happened.  Nobody there seemed to remember him or know what happened.  They wouldn’t give us any information.  “HIPAA,” they said.  Did he take a turn for the worse and die, or remain in a coma?  Did he survive and take what Dr. Mike said to heart and refuse to come back to our ED?  Nobody knows.  All we know is that we never saw our Elvis again.





This author does not divulge protected patient information or information from real life court cases.  Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients.  To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that it should be considered fictional.  Any opinions expressed here are of the author alone and not those of epmontly, WhiteCoat, my employer or any of the hospitals with which I am affiliated.


Saturday, September 29th, 2012

By Birdstrike M.D.


I was driving home from a night shift and the scorching sound of Texas guitars flamed out of my car speakers.  The group ZZ Top was old, but the song was new.  It went like this, “25 lighters on my dresser, yessir.  You know I gotsta get paid.”  Mostly, I was shocked that any members of the band ZZ Top were still alive, let alone putting out new music that was actually getting airplay.  Also strange, is that the song is a remake of an old rap song.  The lyric reminded me of a patient who I won’t name.  It would be a safe assumption that he was a gang member.  He wore saggy, baggy pants, and was heavily tattooed and shirtless.  He either spent 8 hours a day in the gym lifting weights, or ate a healthy diet of steroids.  If he had killed half as many people as his tattoos indicated, it was certainly in my best interest to keep him happy.  This was one patient satisfaction score I would ace.  I’ll call him Lighterman.

“Yo doc!  You gotta fix my hand, man,” Lighterman said in his gang accent.  He held up his bleeding hand.

“What happened?” I asked.

“I used my knife to open a bottle of some Robitussin to put in my beer and I slipped,” he said.  “My brother is home right now getting wasted on my stash.”

“Robitussin in your beer?” I asked, half amused.  “That could kill you, you know?”

“Aw yeah, boy.  It’ll light you up, man.  You should try it.  You a doctor!  You can have all you want, anytime, man.  You got it made,” he said.

“Uh, no.  I would never do that.  Let’s take a look.”  He had a 2 cm laceration on the back of his hand.  I prepped, draped, anesthetized and explored it.  “Looks like you’ve got a partial extensor tendon laceration,” I explained.  “It would be best to have it repaired by a hand surgeon.”

“No way.  I got deals to make and hearts to break, man.  Ha!” he laughed.

“I’ve heard that one before.  I’m not joking, though.  This is serious,” I said.

“You got 10 minutes and I’m gone, dog,” he said.

Suffice it to say that my best “against medical advice” warnings about limb-threatening bad outcomes and signed paperwork did nothing to dissuade him.  He showed no outward signs of drug or alcohol intoxication and certainly would not have consented to blood or urine testing to prove otherwise.  Although, his judgment was clearly very poor, he understood the risks of not getting the best treatment for his injury.  He just didn’t care.

“I don’t got time to go see your specialist, either,” he added.  “I trust you, man.   You look like that TV doctor from back in the day, Doogie Howser, only younger, smarter, with a bigger head and skinnier neck,” he said laughing.  “Sew on, man.  Get on it.  Plus, if you don’t do it, I’ll shoot you.”

What?” I asked.

“Just kidding, I’d never shoot a doctor as good as you.  Ha!” said Lighterman.  “Here you go, man,” he said and pulled a handful of cigarette lighters out of his pocket.   “A little somethin’ for the effort.”

“No, that’s okay.  I don’t smoke.  I don’t drink or take drugs, either.  Neither should you.  I really don’t need a bunch of cigarette lighters.  Plus, we don’t accept tips here in the Emergency Department,” I answered.

“You don’t drink, smoke or take drugs!?  What do you do?  You’re a tough negotiator, boy!  You’re playin’ dumb.  It’s not enough is it?  Here you go.  All my stash,” and he emptied his pockets full of lighters on the counter.

I was completely clueless about why in the world he would have pockets overflowing with cigarette lighters, or why he would think they would make a good “tip”.  Exhausted at 4 am on a Saturday morning I didn’t really care either, so I stitched him and his extensor tendon, splinted him and arranged close follow-up with a hand surgeon he would likely never see.  I wasn’t happy with the medical-legal implications of sewing up his extensor tendon, but he didn’t leave me with any good options.  It seemed that my tendon repair would be better than no repair and without any follow-up.  Never knowing when someone might light a cigar on the golf course, I took one of the lighters and put it in my pocket for golf day.

From the room next door, my 50-year-old male patient who was brought in intoxicated and passed out peeked his head inside the curtain and said, “Doc.  I need some Dilaudid.  Plus, some Vicodin, please.”

“Joe.  Please, close the curtain.  You’re violating this patient’s privacy.  And by the way, we don’t treat alcohol intoxication with Dilaudid and Vicodin,” I answered.  In the room next door was his girlfriend, in her 20’s, who was also passed out intoxicated.  Her demographic sheet listed her occupation as “entertainer”.  Both were brought in by their friends who quickly dropped them off and went back out to party.  She was starting to wake up, too.

“I wanna get the f— out of here.  NOW!”  she started screaming.  “Somebody got a light?  I need a light!” and she pulled out a cigarette and popped it in the corner of her mouth.

The nurse corrected her, “No, ma’am!  This is a non-smoking campus.  You can’t smoke.  You’ll be arrested.”

I finished up sewing Lighterman’s hand and said my goodbyes.  He flashed me some extensive and involved gang-signs that I roughly translated as, “Thanks.”  He stood there waiting for his discharge papers.  He was the most appreciative patient of the night, by far.  He gave me 25 lighters more than any other patient that shift.  What the heck he thought I was going to do with a pile of lighters, I had no clue.  Sell them? I thought, and laughed.

“Make sure you see that surgeon,” I added, knowing it was futile.

“Don’t worry.  If I have any problems, I’ll have my lawyer call you.  He’s better than OJ’s lawyer,” Lighterman said.  “Just kidding, I’d never sue you.  You’re a good doctor.  I ain’t payin’ the bill, though.  Believe me on that one.”

“Oh, I believe you,” I said as I looked at his name in the computer.  He had registered under the name, “Michael Jordan,” except that was not his name, and he was not Michael Jordan.  He registered under a fake name on purpose.  “See you later…uh, Mike.”

I went in the back room to finish charting.  When I came out and looked around, all 3 rooms were empty.  Lighterman and the two others were gone.  “Where’d they go?” I asked the nurse.

“Once he left, the two others got up.  They both ran in his room as fast as they could and ran out of this ED like they were on fire,” she laughed.

“Maybe they were on fire, who knows?” I laughed.

“You know what was weird?  They both scooped up those lighters like they were full of gold.  I guess she really did need a cigarette.  What she was going to do with the other 2 handfuls of lighters, I don’t know.  Sell them?” she said chuckling.

“Yeah, for what, ten cents each?”  I said.  “Wow.  People never cease to amaze me.”

I shook my head and went in to see the first of the 25 patients now piled up waiting for me and introduced myself.  He was talking on his cell phone oblivious to my presence, so I interrupted and asked, “What can I do for you today, Sir?”

“Okay, I gotta go,” he said into the phone, “there’s some dude here trying to talk to me.”  He hung up.  “I’d like an inhaler, some cough syrup, a Z-pak, Tylenol on a prescription so Medicaid will pay for it, plus a work note for my sniffles.  That’s it.  I’m ready to go,” he said.  “By the way, that was crazy, wasn’t it?”

“What?” I asked.

“I can’t believe that guy tried to tip you with all those lighters full of crack.  That was insane!” he said laughing.  “You know how much he could’ve sold those for?  He must have really liked you.  And those two other kooks got away with the score of their lives.”

“Lighters full of what?” I asked

“Crack.  Cocaine!  That’s how the dealers hide their stash around here.  They empty out cigarette lighters and fill ‘em with crack.  They’re a lot less likely to get caught handing off a lighter than a bag full of crack, aren’t they?  Wow, you don’t get out much do you?” he asked.

“No, I don’t,” I answered.

“By the way, you gotta light?” he asked.

“No.  Actually, yes!” and like lightning I put my hand in my pocket, pulled out the lighter I forgot I had pocketed, threw it on the counter and called,







This author does not divulge protected patient information or information from real life court cases.  Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients.  To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that it should be considered fictional.  Any opinions expressed here are of the author alone and not those of epmontly, WhiteCoat, my employer or any of the hospitals with which I am affiliated.


Those Shoes

Friday, September 14th, 2012

By BirdStrike M.D.

Some cases burn into your brain like a hot branding iron, for whatever reason, and never really leave.  This was one of those cases.

One hectic morning before my shift, my wife and I rushed around the house trying to get our kids ready for school.  On this day, my daughter was to go on a field trip where the teachers would walk the kids through the city to the local park to study the small oasis of nature in the “concrete jungle”.  Before such field trips I would always wonder, how the teachers can corral all those little kids safely through such a crazy city, crossing such busy streets.  “We are super careful,” the room Moms would ensure everyone.  My wife had gone on a couple of these field trips and she remarked at how organized they were and how good the kids listened, holding hands and singing as they walked in a long hand-holding train through the city.  “Okay,” I would say, “sounds like they’ve got it under control”.

Working in the ED, I knew better.  At this point in my career, I had already seen most forms of human tragedy up close and personal.  Sometimes I wonder half-joking, half serious, if there is something called “PTS-ED-D”, or “Post Traumatic Stress Emergency Department Disorder”?  Of course, not, that’s nonsense.

As we rushed to get the kids ready for school, my 5-year-old daughter beamed her baby-blue eyes up at me, hair curly golden-blonde and said with a life loving smile, “Daddy!  Can you put my shoes on, please?” She proudly raised her adorably tiny and favorite new hot-pink glitter shoes and handed them to me.  I put them on her and she blew me a kiss.  “Bye Daddy!  I love you,” she said.

“I love you, too.  Have a great day at school,” I said.  At light speed, they rushed out the door and I rushed to work for the early shift.

Two hours into my chaotically routine shift the charge nurse gets off the phone and says, “Buckle up guys.  We’ve got a pretty bad one coming in.  EMS will be calling in any minute: Trauma, level I, no vital signs.”

“Alright, guys.  Trauma room one.  Let’s go,” I say.  Before any radio call, the ambulance doors blasts open and all I see is a blue swarm of huge EMS men around a rolling ambulance stretcher, one up high doing chest compressions with sweat pouring off his red face like Niagara Falls, and all the others busily working this trauma looking notably more stressed than usual.  As they roll down the hallway towards us, still I see nothing but a sea of big burly EMS men and haven’t seen even a glimpse of an actual patient yet.  As they roll around the door and make their left turn towards me, a tiny but searing flash of hot-pink and glitter explodes into my eyes through the sea of blue uniforms.  “Oh… My… God…” I think to myself.

T  H  O  S  E     S  H  O  E  S

Hot-pink.  Glitter.  Tiny.  Time stood still.




I felt my heart rate dropping.  I was getting dizzy.  Was my worst nightmare about to come true, right here in my own ED, on my own shift?  I needed to see the face.  NOW.  I was afraid the see the face.  As “clinical” as I could be to get through the most difficult parts of my job, this was too much.  As the stretcher came towards me, the sea of uniforms parted and I saw her.

A girl 5 years old, with tiny hot-pink and glitter shoes.

The hair:  brown and straight.  The eyes: emerald-green.  A beautiful child.  Someone else’s child.  She was frighteningly reminiscent of mine, with the exact same shoes, but with skin now fading to a ghostly white-gray and eyes as lifeless as a doll’s.

Time exploded back into the usual frenetic light-speed trauma-code pace.  Airway  Breathing  Circulation  Line 1  Line 2  Monitor  Fluids  Blood  X-rays  Needle-chest  FAST-scan  Chest-tube.   ATLS protocol at light speed.

We ran the code for what seemed like forever.  We did everything, and then some, and then some more.  We did everything we possibly could for this child who was on a school field trip, run over by a drunk driver who jumped a curb in his truck on a Monday morning.

Pulse, none.

Pressure, none.

Pupils, fixed.

Pupils, dilated.

This beautiful child was dead.  Someone else’s beautiful child was dead.  My worst nightmare was not coming true.  Someone else’s was.

I went back to the old dictation room to regroup.  I could hear the sound of co-workers trying not to cry.  I could hear the sound of one of my other patients saying, “G-d d—n it!  What the hell is taking so damn long!?” I had to prepare myself to break the news to the parents.  There is no way to sugar coat this type of news, no way to make it any easier.  I felt like I was going to die.

I walked into the room and greeted two parents on their knees crying, praying, horrified but certain we could save their child with the same miracles they had seen on TV.  They looked about the age of my wife and I.  Their faces were hauntingly familiar.  I was about to drop a nuclear bomb on their lives.  The words cracked and fumbled as they came out of my mouth.  “Hi, I’m doctor Bird.  Are you the parents of…?”

I’ll never.




T  H  O  S  E     S  H  O  E  S



This author does not divulge protected patient information or information from real life court cases.  Any post that appears to resemble a real patient or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information about real patients.  To the extent that any post is based on the real life experiences of the author, names, dates, ages, sexes, locations, diagnoses, and all other factual information are routinely changed to the extent that it should be considered fictional.  Any opinions expressed here are of the author alone and not those of epmontly or WhiteCoat.

Obama vs. Romney vs. Honey Boo Boo

Sunday, September 9th, 2012

By Birdstrike M.D.


Once again, our upcoming election will have great impact on future health care policy.  Obamacare will either be kept intact, repealed or altered.  This will have great impact on patients, physicians in general, and especially Emergency Physicians.  By whom they choose to lead us, the electorate will decide whether treatments are rationed or not, and if so, to what extent, by whom and on what basis.  They will decide whether doctors are free to choose what tests to order, and if so which ones, how many and for what reasons.  Also, they will influence physician salaries, by choosing the leaders who will determine Medicare and Medicaid reimbursement, which generally lead with reimbursement cuts that private insurers follow.  Our electorate will determine our malpractice liability by choosing our leaders who will either, strengthen, weaken or ignore tort reform.  They will influence which charting systems we are required, or not required to use, given that Obamacare has already written into law penalties for failure to implement electronic health record use.  By whom they choose to lead us, the electorate will influence how much we are, or are not burdened by regulations, and whether these regulations will be logic based, or cumbersome and irrational.

The choice of the electorate will affect which pay for performance measures we and our salaries are subject to.  Likely, they will also influence which form of patient satisfaction surveys we are or are not subject to.  Also influenced, will be our overall workload depending on whether patients are adequately insured, by which doctors and in which settings.  This will influence who is most, or the least burdened by the overall shortage of healthcare providers, and whether or not the millions of newly insured will end up in primary care physicians’ offices, shunted to emergency departments with growing wait times, seen in specialists’ offices or remain uncared for.  How informed, or uninformed our electorate is, particularly as it relates to health care policy, will affect the health of our patients, our livelihoods as physicians, not to mention the health of our families and ourselves as patients.

Since the end our nation’s two major party conventions, it caught the attention of several major news organizations that on any given night of the week of either the Republican or Democratic National Conventions, that both parties faced stiff competition for viewers from the new and controversial TV show on TLC called “Here Comes Honey Boo Boo,”  which TLC describes on its website as a show where a “six-year-old pageant sensation proves that she is more than just a beauty queen.” As said by the child’s own mother, June Shannon on ABC News, “We are a little redneckish, and we live in Georgia and that’s what people do in the country — get muddy and have fun with the family.”  In the first episode they take part in the “Redneck Games,” bob for pigs feet and take part in a “mud pit belly flop.”  Although fortunately the overall viewership of the conventions was greater according to ABC News, this show did draw more viewers than Fox News’s coverage of the Republican National Convention on at least one night and tied the ratings of the Democratic National Convention during Bill Clinton’s speech.  Does anyone know where Honey Boo Boo stands on health care?

Apparently, a large part of our electorate would prefer to watch a show like TLC’s “Here Comes Honey Boo Boo” over either convention.  Whether this is more of a reflection on our political parties, our electorate, our “Democracy” or (hopefully) none of the above, I am not sure.  However, two months before an election where we will choose a President, seat our entire House of Representative and 1/3 of the U.S. Senate, that will have a huge impact on future health care policy, I think it is worth discussing how informed or uninformed, and how engaged or apathetic our electorate is about the health care issues at hand.  Their decision will affect our patients, our health, our work environments, our salaries, and countless details of our health care system going forward.  It is our responsibility as physicians to educate the public on this part of their vote and its potential consequences.

Have we done our job as physicians to educate our patients, friends and co-workers on the issues at hand and how important this election is?  Have we come to grip ourselves, with how much this current election will affect the lives of our patients, our families, as well as every aspect of our profession?  If the answer to either question is no, then between now and Tuesday, November 6th 2012, we have a lot of work to do.

Which did you watch, the Republican Convention, Democratic Convention, or “Here Comes Honey Boo Boo”?




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  • William Sullivan
  • Michael Silverman

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