How I Remember It

It's a cold winters day in February. Friday exactly, the day most people pack it in, take it all home. I’m on the 2pm to 10pm shift. Not bad. Usually those are peak hours, a good time to work. But on this Friday afternoon it’s a little slow.

I working with one of our new docs. She just completed her residency last year. She’s green, nervous, frequently seen looking up doses for penicillin and the like. She has potential but needs some polishing. I know only I can help this young apprentice to one day be an ER Jedi.

At my hospital there is one thing every ER doc fears……..Delivering a Baby.

In our current health care climate, many hospitals have gotten out of the Labor and Delivery business. Mostly because of profit and liability issues. Anyway, not all hospitals have an L&D suite or staff Obstetricians. At my hospital we don’t have any ER coverage for OB/Gyn. So we don’t birth no babies.

Anyway back to me.

On this blustery Friday afternoon we are strolling along. Suddenly a red truck speeds to a stop outside our ambulance doors. A young man jumps out and appears to be yelling for help through the glass. Sometimes patients do this. We always go check it out, but it better be good.

It’s good......... His girlfriend is in labor.

Tension heightens as the staff help the 19 year old out of the car and checks out the situation. This could be an emergency, the next sounds from the room…

"We need a doctor in here."

The patient is screaming, obviously in the throws of a contraction. She says she is 5 and half months pregnant. That’s 22 weeks. A baby is considered full term if over 35 weeks. A non viable fetus is less than 20 weeks. 22 weeks is no mans land. 22 weeks is premature. 22 weeks is bad. If born, the baby could live, but at 22 weeks there will be complications. We are talking neonatal breathing machines, umbilical IV lines and feeding tubes.

This girl is 19 years old, this is her first pregnancy, she has had no prenatal care. To make things even better she is stick skinny. By that I mean she has a very small pelvis. In Alabama there is a thing referred to as birthing hips. Good birthing hips are wide and the misses can spread her legs far apart creating a wide opening. I’ve seen good birthing hips that you could pass Volkswagen through. Bad birthing hips are small framed girls, tight pelvis and it’s even worse if it’s your first pregnancy. Bad birthing hips define this young mother.

So the first step is to see where we are. I slip on a glove, add a little KY jelly and insert my fingers into the vagina hoping to feel a closed cervix. What I actually feel is a baby’s head. The nurses are staring at me in anticipation waiting on the news....... "We are going to have a baby here." is my response. "Oh sh*#!" is the general refrain.

Accounts of what happened next differ, but this is how I remember it….

The nurses generally begin to panic. There is confusion. Some of the staff are yelling, some are starting to cry, a few passed out and one or two are on their knees praying. This is a scary situation, they need leadership, they need a hero.

So I stand tall and brave between this young girl’s thighs. I take both my hands to my v-neck collar of my scrub shirt and rip it down the middle exposing my pectoralis muscles and 6 pack abdomen just beginning to glisten with sweat. I run my fingers through my perfect hair and raise my hands to shoulder height. "Gloves!" I call, and gloves are placed onto my steady hands. "Gown!" I call and I am draped like a priest giving his most holy service. In a calm, confident tone I look at the charge nurse, "Get me the delivery tray, I am going to usher in the miracle of life."

My young assistant doctor is panicking. "Excuse me Doctor Gibson, but her pelvis is too small! You will never get the baby out! No doctor in his right mind would even try this! What are we going to do?" I have no choice but to slap her firmly across the face. "Dr. Barnett, remain calm. I am no ordinary doctor." Ashamed that she has lost her composure, she quietly gathers herself.

I insert my index fingers into each side of patient’s vagina around the child’s head. I begin to stretch the vagina open with all the strength in my fingers. An IV has been started but I can’t give any pain medications. Narcotics in a preterm delivery could depress the child’s respirations. Mom is going to go naturally. Mom is pushing and screaming. I am stretching, a ER tech in the back of the room just vomited. The contraction subsides.

The baby’s head is facing the wrong direction. Meaning its nose is facing up. Usually babies come out with the nose facing the floor. Ideally I would like to try to rotate the baby but there is no time and the child is lodged into position. Another hurdle I must overcome.

This is getting bloody. I call for suction. I continue to stretch. I can see the head well now. If the baby gets stuck, I am going to have to start cutting. I must stretch, she must push hard!

At the crescendo of the 5th contraction the baby’s head pops out. One more good stretch and I reach my fingers under the child's armpit, rotate the body and with one more push the baby is out.

"Clamps" I state commandingly.

"Scissors!" The child is now free.

I am now holding the child across my right forearm and tap it on the bottom. The room is filled with silent awe.

The next sound we hear are the eeking of a newborn’s cry.

Elation fills the room. Tears of fear have turned into tears of joy. Nurses and complete strangers are hugging, music is in the air and as I listen closely, I can hear the sounds of angels singing.

View from the Other Side

I have a work routine. I dress in scrubs, sometimes a white coat. I talk with patients, extract their symptoms, do an exam and formulate a problem list. This is usually followed by ordering some labs, sometimes X-rays, and starting treatment. I chat with friends. I have my perspective, this is my side and that’s where I live.

I have never been a patient. I’ve never been on the other side. Until recently....

I was visiting my parents in Birmingham and we were having a "fun day". We ate greasy hamburgers for lunch, had afternoon coffee and met my sister and her family for some spicy Chinese food. Fun enough?

In the past few years I have had some stomach problems, initially self diagnosed as indigestion, later as gastritis and finally an ulcer. The cause of my stomach problem is all on me. Fast food is often my best option and I have a daily habit of a 6 pack of diet coke. Not to mention my job can be a little unnerving at times.

So on February 6th I woke up at two in the morning in excruciating pain. I basically felt like I had been stabbed in the stomach and someone was twisting the blade. I drank a half bottle of pepto, no luck. I took a Prilosec, no help. I drank milk. I drank water. I tried to make myself puke. Nothing helped and my pain was only getting worse. Changs sweet and spicy chicken is having its revenge. Damn the Asians!

It’s funny (not gay), when you are at your weakest moments, how your imagination can run away with you. Is it my stomach? It's never been this bad. Could be gall bladder. Could be a kidney stone. Probably not appendix, but could be. This is killing me. Could I have a gall stone lodged in my common bile duct? Possible. Could I be developing pancreatitis? That's really pain full and this is really pain full. That could mean surgery. Could I have a perforated ulcer? This is actually my worst fear. That's definitely surgery. This is not going well.

So I come to the first decision every person on the other side (the patient) makes. They decide to come to the hospital. This was not as easy as I thought.

It's the middle of the night. I'm not at home. I am about to ask my 74 year old mother to drive me to the ER. I'm in agony. This completely sucks. After 30 more minutes of anguish I decide there is no other option.

I have one friend who practices in Birmingham. I call and of course she is not on shift. At this point is doesn't matter. If I am leaking my stomach contents into my peritoneum there is only one place I'm going in Birmingham: UAB.

I arrive and am quickly triaged. I go straight back. (Usually not a good sign). I meet Dr. Buckman. He is about my age. He knows I am a fellow pit doc (that's slang for ER doc. If you really want to be in the know refer to the ER as "the pit". Usually because the ER is always located on the bottom floor of the hospital but also considered by many as a place of primordial ooze that some of the most basic forms of life miraculously survive. Anyway, it is 4am now and Buckman looks a little tired. I give him a succinct story about my symptoms but leave out my list of possible diagnoses. That's his job. I should stay out of the way.

He examines me and says "I think you've got a perforated ulcer". Oh great! This Buckman is a real wordsmith. So much for sugar coating.

That means major surgery. I'm 300 miles from home. I've got obligations this weekend and I'm back on schedule in the ER starting Monday. I am not prepared for this and my entire career is based on being prepared for an emergency. It's just not a good time.

Buckman plays his trump card, "Well, if you've got it, there are no other options."

I know he's right. There is an unintended psychological warfare going on in the hospital. I am in severe pain. I have on a hospital gown and a pair of boxers. One person walked in while I was changing and I'm pretty sure at least 3 people saw me naked. But since I've got this burning fire poker in my belly, I could hardly give a care. I'm pale and feel lousy. I don't know any one's name. Someone whom I have never met and who has never met me could be opening my abdominal cavity in the next few hours. I am at their mercy. I feel helpless.

So to make a long story short, I ultimately did not have a perforated ulcer, just an ulcer. I got outstanding treatment and was discharged in a much improved condition.

As for my treating physician, Dr. Buckman was a flat out stud. I knew he was concerned. Not by what he said but by what he did. He showed up in X-ray after I had my films done. Later I saw him again in the CT scan control booth looking at my images as they were being developed. He didn't have to do that, but he knew that something could be bad and he didn't sit around and wait on the answers to come to him. He actively sought them out. It's those kind of actions that separate the great from the good.

Barbara, my nurse, was fantastic. Like all great ER nurses she has the most face to face time with the patient. She started an IV, was quick with the meds and double checked the doses at the bedside in my clear sight. I only got a small dose of pain medicine (my request) but she hooked me up to the monitor just to be safe. I (and she) knew that probably wasn't necessary but still it was comforting. She wasn't taking any chances and I really appreciated that. I joked with her and she joked back. I was facing a crisis but I was confident she knew my case and was looking out for me. She was a pro.

There is a thing called "The Patients Bill of Rights". As a physician, I have always rolled my eyes at this idea, thinking what is the point? I am on the patients side. I want to get the diagnosis right. I want them to get the right treatment. But now I know the Patients Bill of Rights is not about me, it's about the patients' trust.

So I have written the ER Patients Bill of Rights:
1. The Patient has the right to be afraid. We know that you don't know us and that is naturally frightening in this critical time.
2. The Patient has the right to be believed. I will believe you are sick.
3. The Patient must know that the doctors and nurses are asking them for their trust.
4. The Patient must trust that I will do the best for you to come up with the right diagnosis. Not of of fear of being sued, but because I want you to get better.
5. We (including you) are part of a team. We must all work together and do our best to solve this problem.

*This Bill of Rights may not apply to everyone. If you come in weekly and have cried wolf too many times, you have betrayed our trust. And this is a two way street.

So what have I learned from being on the other side?
It's miserable. But when it's miserable I want to be the kind of doctor that (and I can't believe I'm saying this) is a comforter. It's not just getting the diagnosis and providing treatment. It's about reaching out and really helping someone in a time of need.

Surreality Show

"Most people you meet are asleep, and the ones that are awake live in a state of constant, total amazement" -Joe versus the Volcano

It’s a Saturday night and I’ve got the late shift in the ER. Weekends always bring interesting patients to the mix.

Those of you who aren’t in the medical business would be surprised at the number of people we see who actually don’t want to live. Everyday (and I mean everyday) we see at least one patient and usually more with the complaint of “depressed, wants to commit suicide”. For everyone one of these we see five more with “waste basket diagnoses”, examples of these are: chronic fatigue syndrome, myofascial pain syndrome, hypoglycemia, mitral valve prolapse, there are many more. These patients take many medicines, herbs, therapies and the like. Their doctor doesn’t know what to do with them but feels obligated to come up with a diagnosis so they get one of these labels. They are sick, they have “poor health”.

Back to Saturday, I’m working with 10 patients and 3 have intentionally overdosed and one is thinking about cutting her wrist. Not a good mix.
My suicidal group ranges in age from 20 to 60. None of them want to live.

On the other hand my partner has a patient. Her patient is 37 years old and has terminal lung cancer. Diagnosed originally two years ago, he has undergone numerous operations, chemotherapy and had little success. His tumor is adenocarinoma of the lung (not necessarily caused by smoking) and is very aggressive. He is down to 90 pounds, has a feeding tube and bed sores. He is dying and there is nothing more we can do. He has come to the hospital tonight because he has fired his Hospice nurse and has thrown out his home health team. He is angry with his parents, doctors and family. He is not ready to die. He wants to live. “I’m just not ready”.

It was a surreal moment. I am surrounded by relatively healthy people who want to die and looking at a very sick guy who desperately wants to live. Life is unfair.

It makes me think of one of my favorite movies, Joe verses the Volcano. Basically it’s about a guy in a dead end job, living a dead end life. He finds out he has a terminal illness (brain cloud) and only has a few months to live. So for the first time ever he chooses to live. The movie has moments of great dialogue and symbolism. It has a silly ending but the message is wonderful. I highly recommend you watch it.

The best part is that it’s message is true. So few people actually live life. I have met many people in my 39 years and I have learned this: money won’t make you happy, power won’t do it either. I think it comes down to doing a job you love, having real friends, and not taking the rest so seriously. I think it’s about trying new things without a fear of embarrassment. Most importantly don’t waste a day, you’ve only got a few.

Now “Take me to the Volcano!”.

http://www.youtube.com/watch?v=oGLKnAvzlg4&feature=related

Complaints

Believe it or not, sometimes we in the medical profession get complaints. We always have a response to these complaints. When this happens to me, I tell my side of the story. It’s usually the truth.

The problem is that the patients who complain usually have no grounds to complain. The patients who have a legitimate gripe usually don’t bother. They figured they survived their Emergency Department trip and that’s enough.

Complaints usually break down into three main categories:

Common BS complaints.

You/They didn't do anything for me. If you see any doctor you are guaranteed to get a history and physical. Sometimes that's all that's needed. Somethings can't be fixed in the ER. Long term illness, chronic problems, mental illness, the flu. Sometimes all patients need are a few Tylenol and a big shot of "suck it up". There is just no magic bullet.

I saw a patient 2 weeks ago who had advanced Alzheimer's dementia. He fell at his nursing home and bumped his head. His wife accompanied him to the ER. I could have run a battery of tests and spent thousands of dollars. But the bottom line is it wasn't going to change anything. His wife was frazzled, struggling, watching her loved husband slowly become a victim to this horrible disease. (My wife had to walk down this road with her mom.) I talked to her about our options and we decided to send him back to his unit. No prescriptions, no test. I didn't really do anything other than talk and listen. After our discussion I walked around the bed, put down my clipboard and stethoscope and held her in my arms. She cried for about 5 minutes. The best care I provided that day was giving this lady a hug. No charge for hugs.

The doctor didn't take me seriously. If we aren't freaking out, you shouldn't either. We are trained to identify what "sick" looks like. It actually takes years of experience. One bubble in the IV tubing is not going to kill you. If the monitors start beeping (and you are conscious) it's usually not a big deal. This frequently comes off as callous, but what it really means is everything is okay for now. If your kid got hurt and is crying that's actually a good thing, but it makes mom terribly anxious. If your kid gets hurt and is not crying- that's the kind of thing that gets me anxious.

Insider Heath care tip: If you only see one nurse and your ER doc is acting casually, that is good. If you look up and see more than one doctor and three nurses in your room, things are not going well.

Middle ground complaints

The doctor wasn’t friendly enough. This one really gets under my skin. Most doc’s are polite. The point is we are trying to get some important information out of you. So occasionally I will interrupt a patient to keep them focused. It probably doesn’t matter if you had your tonsils out when you were kid. It probably doesn’t matter that your great grandfather was allergic to shellfish, vitamins are not medicine and cats make you nervous. None of those things ever matter unless we develop some new therapy that involves cats. So if you, as a patient, start rambling, I’m going to cut you off. No offense, but I'm trying to stay focused on your emergency today. Don’t take it personal.

Legit complaints.

It was too cold in the room. Patients are right on this one. The nurses are working hard, walking at a fast pace, usually with a little adrenaline pumping. They sweat easy. The patient on the other hand is forced to strip down to a paper thin gown and sit on a cold examination table. Occasionally we run cold IV fluids and sometimes you have a fever which makes you feel cold. We can really poor it on here. If you ask for a blanket, most times you’d do better knitting one. People are dying in here! And you want me to stop to get you a blanket. Ask for one and you may get a eye roll. Actually my nurses are pretty good at this. I myself have gone and fetched a blanket or two. But we don’t do it consistently so don’t get your hopes up. No kidding people are dying in here so we keep our priorities. For the life of me I don’t know why we don’t keep blankets in the room. I’m sure it’s a cost saving measure. Less linen means less laundry fees.

By the way don’t get cute and bring your own blanket. You will be made fun of for this and all will think you’ve been in the ED a little too much.

We will starve you. There are many reasons why we don’t let you eat. Primarily we want your stomach empty in case you decide to become unconscious for some reason and vomit. You could choke on your vomit and suffocate. You don’t want me to suck vomit out of your trachea and frankly I don’t want to. So it’s really a win/win.

I was kept in the ER too long. This is the king of legit complaints. After I see you and decide you need to be admitted, I do a little paperwork and have the charge nurse request a bed. You think it’s all down hill from here, but wait. Many times there is no bed available. The nurse has to copy the chart, do some more orders and call report to the nurse on the ward. Sometimes the nurse on the ward is available, sometimes not. Your room has to be cleaned. Then you have to be transported (usually by a transport tech who may or may not be available). This can drag on for hours. At our local university hospital some patients have been kept in the ER for days. Patients get angry with me about this but there is nothing I can do. I can crack open your chest and massage your heart, but I can’t seem to get the floor mopped in room 509.

I used to not always feel so powerless. Once I had a tantrum. I went up to the ward found the nurse, the unit manager and the bed and called down to the ED to have the patient immediately transported. This did not go over well. I did get a phone call from the "doctors behaving badly committee". But for a few months things did seem to improve. I tried a similar trick the other night and got a tongue lashing from my fiesty charge nurse and the nursing supervisor. It does amaze me how I can go to hotel without any advanced notice, ask for a room, and the zit-faced, high school educated night clerk can get me in a room in about 10 minutes. Why can't hospitals do that? Hospital administration does not like that question and they don't think my zit-faced clerk analogy is cute one bit.

What people don't complain about.

Whats up with all the cussing and nudity? I have to say the ED is R rated material. We see a fair amount of drunk, drug addled, nut jobs. They scream profanities and have no problem at all walking around naked. You can hear them all over the hospital and I know the deacon and his wife in the room next door are getting an ear full. Sometimes I'll even apologize to patients and their families for the show they are getting but amazingly they all seem okay with it.

The Bill. The cost of health care is insane! Yet people who have insurance seem to willingly pay their copay thinking that their insurance is going to take care of the rest. Keep dreaming. Your insurance company will deny everything they can and ultimately pass this cost on to you. I sutured a kids leg the other day. Took about 4 stitches and about 10 minutes. We hit them up for about 400 bucks. I got about 30 for the gig. I have no idea where the rest is. There is a laundry list of explanations but that's for another time.

The food. Hospital food is a cold, saltless, sterile mess. Yet patients suck it down like it's prime rib. We often see the complaint that "grandma has just stopped eating". Then I'll watch her inhale a Salisbury steak, a carton of room temperature milk and pimento cheese spread like it's the last meal on earth. For what you paid for that meal you could have taken the whole family to Ruth's Chris.

In summary there is an art to complaining in the ER. Basically keep your complaints realistic. If someone is being a real A-hole, call them on it. But keep in mind we only partially control the environment. For some reason, you've wound up in the ER, and that was not your plan, so you're already having a bad day. Expect the staff to be professional but don't expect a lifelong friendship. We do see people in crisis everyday, so it's only natural to get "dumbed down" to all the emotions. It doesn't mean we don't care. Help us out and we will go the extra mile to make sure you get what you need.

The Evil Empire. Girl Scouts!

There is badness in the world.

On Wall Street, on your street, you can see it at a number of levels. Explotation is a fact of life. You could argue that since the industrial revolution everyone gets exploited some.

One day, I bought a car. A group of people designed and built that car. They had incurred cost: materials, labor, shipping, advertising, etc. They sold that car to me for more than what the car was worth. They made a profit. Was I exploited? To a degree the answer is yes. The alternative was I could walk everywhere, or build my own car, but that’s really nonsense. But was I morally wronged? No, I knew the deal going in.

Here is a different example. My oldest son doesn’t really like candy. My middle son loves candy. On November 1st last year my oldest son, Wyatt, “sold” his Halloween Candy (retail worth about 8 bucks) to my middle son Graham for 20 dollars, (money he earned for his household chores). Was Graham morally wronged? Yes. He got a lousy deal (not morally wrong in itself). He was wronged in the fact he did not have the insight to see he could have bought 5 times the amount of candy for the same price. They were 8 and 7 years old, so no big deal. Graham learned a valuable lesson and won’t be making that mistake again. But what if Graham had been conned by an adult? That would have been reprehensible. Surely no adult would do that to a child, right?...... Wrong. Enter a little group called The Girl Scouts of America.

Every year at this time, I get a knock on my front door by a hapless pawn of one of the biggest exploiters of children in America: the Girl Scout. Dressed in their drab little uniforms, they stumble out of their mom’s minivan, slouch up to my door and eek out “Mister, do want to buy some cookies?” This starts the exchange.

“Let’s have a seat here on the steps.” This usually gets the window rolled down from the minivan.

“Why should I buy your cookies?”
“I am selling them for my troop.” Toothy grin.
(I guess these troops form companies then battalions and so on, but I don’t know that for sure and don’t ask. It’s already kind of para-military. I admit it would be much cooler if they dropped their cookies out of C-130’s)

“Why are you selling them for your troop?”
“They told me to.”

“Are you getting paid for doing this?”
“They cost 3 dollars a box.”

“No. That’s not what I asked. How much of the 3 dollars to you personally keep?”
“Huh?”

My questions continue.

“What’s your cut?”

“What are you getting paid per hour for selling these?”

“Does your employer provide you any benefits?”

“Are you getting mileage?”

“Are your time and energy valuable?”

“Are you valuable? Are you not valuable?”

This barrage usually gets tears but I am making a point here.

So I cut her a break and make the girl scout a deal.
“Here’s the deal. I am not going to buy your girl scout cookies. Not now, not ever. But if you go home and make me some cookies, we will work out a price and you will have the money to spend how you want. You can keep it, you can spend it, you can invest it, you can give it away. It’s your money and you get to decide what to do with it. The bottom line is this: You produce something of value to me and you get paid.”

Fighting back tears, in a whiny voice: “But I don’t make the cookies, I just sell the cookies.”

“Well I’m not going to let you make a fool of yourself, so get off my porch”.

Here comes mom.

“Why are you being mean to my daughter?”
“Why are you teaching your daughter to be a loser?”

Mom grabs her snotty kid and storms off. They will be back next year. Still not knowing a thing about how the free enterprise system works.

Here are some facts:

Your local GSA “troop” gets about 50 cents a box. The GSA’s own sources say about 17% of the money goes to the troop. The “troop” is loosely defined and not necessarily your child’s troop.

The GSA is genius. They make average cookies. (Okay, the thin mints are above average). They have a sales force of several hundred thousand children. (I thought there were laws against that) And they pay their saleswomen a giant sum of ZERO! For emphasis, they pay their sales force ZERO. Think about that.

Even better, their advertising is minimal. Retail delivery is not their problem and there is no return policy.

My neighbor Girl Scout has to buy her own lousy uniform, pay dues to join and even has to purchase her merit badges. The field trips are subsidized by parents and supervised by parents who also get paid a big fat ZERO!

Why didn’t I think of this!

Nothing is more un-American than the Girl Scouts of America. Believers are teaching their daughters to work hard for someone else and then give their earnings away.

Did you know the GSA has several national and international head quarters. They have a multi-million dollar budget. The main headquarters is on 5th avenue in Manhattan and the CEO makes $650,000+ per year. The best part of all: it’s a non-profit organization. That’s all well and good if you plan on raising non-profit kids.

Oh but wait, the top sellers for each troop get a prize, usually a t-shirt and a certificate. The certificate says in old English “This is to certify on this day that Molly is the biggest sucker of all her friends. Sincere thanks from the Girl Scouts of America.”

Well that’s what it should say.

The Arkava Soution to our Health Care Crisis.

No one is more attuned to the heath crisis in the United States more than the providers of that care. This issue has come to the forefront in the last 5 or so election cycles. Of course, little has changed. The problem in a nutshell is that, for many reasons, health care is expensive. The costs are so prohibitive that people cannot afford health care without "health insurance". Most data cite that about 50 million American citizens are uninsured.

So the problem is this: How to get more Americans health care?
A popular democratic solution is Universal Health Care, which many see as a single payer system administered by Uncle Sam.
The popular republican is answer is a free market solution. Which is basically gives citizens tax incentives so that they can buy private insurance. This plan attempts to create a competitive market that will drive health insurance premiums down.

While opinions vary, most providers favor the free market system. We have already tasted the bureaucracy of Medicare and Medicaid. Many doctors already cap their practice with respect to the number of patients they will take with these plans. However a growing minority are supporting Universal Care, essentially saying something is better than nothing.
Recently, in one of our monthly journals, an editorial was written by a supporter of Universal Health Care. I have the great honor of working with a physician who wrote a response to this editorial. Todd Arkava MD is a fellow ED doc who sees the health care crisis daily. He is compassionate, empathetic and always acts in the best interest of the patient no matter their "insurance status". He served in Iraq and is now a retired officer from the United States Army. So when Doctor Arkava speaks of duty, service and citizenship, few physicians can match his qualifications. His rebuttal was so excellent, I have included it here for your review.

Dear Editor:
I want to comment on Dr Hockfield’s article on health care reform, as I see some major flaws with his reasoning. I think the problem that most people have when trying to solve the high cost of health care in this country is that they have trouble stepping outside of the current paradigm. Free market health care would not work with the current system, but where is it written that the system has to be the same?

First of all, people do not have a right to health care. Dr Hockfield claims that "access to basic health care is a right," but then goes on to say that certain physician services are included in that right. There is no way that a person can have a right that infringes on the rights of other people. These are called positive rights, and are morally flawed. A person can have a negative right- the right to be free from harm by another person, but health care requires that other people provide goods and services. If I have a right to health care, the doctors, nurses, pharmacies, and drug companies will have to give me their product and service for free, which infringes on their right to be compensated for their labor. What do you want to do to people who refuse to give away their work for free? Steal money from them in fines? Put them in a cage? Once you force someone to work for free, that person has become a slave, which is prohibited by our Constitution.

Claiming that people should have a right to health care is akin to saying people should have a right to food and therefore all restaurants and grocery stores must give their products and services away for free. Is the government going to pay for these things? How will they ration those dollars and determine who is deserving? Will they also throw money at another commission with a top-heavy bureaucracy? What if a physician does not want that money with all those strings attached? Is he or she free to make those decisions, or is the doctor forced to provide that service on penalty of being fined or jailed? The socialist system cannot work without threats of violence. Am I the only one who finds that troublesome?

Dr Hockfield makes the argument that the suppliers of health care have too much control over the demand. I agree with him, and this is where the free market could take over. Why does it cost $800 for someone to come to the ER for an uncomplicated broken arm or laceration repair? Why can’t someone spend 6 months to be trained in simple procedures and make a living in his or her own private clinic? No, there is no medical degree being given, but they can let the free market determine if they are doing a good job. They have a great incentive in that they will go out of business if they do shoddy work. Before you suggest a regulatory body to oversee this industry, think about how much the costs will go up to fund the bureaucrats in this endeavor. We are trying to keep costs down, and the free market is very good at that job. I am sure these people would be happy to receive $50 for minor cuts and breaks, and they could even use dangerous drugs like: lidocaine, tetanus boosters, and cephalexin.

We have a monopoly on services in this industry, and the free market cannot exist without competition. What would hospitals do to compete with this new sector? They would have to lower prices. If a person wanted a thorough physician evaluation, he or she could choose to pay more. Much in the same way you decide what to eat for dinner or what type of television to buy, cost plays a role. People make decisions about their health based on cost all the time (types of food, cigarettes, alcohol, saturated fats, etc).

Pharmaceutical companies are also hampered by FDA restrictions, which make them take almost 20 years to get a new drug approved. They in turn have to charge ridiculous amounts of money for their product to recoup these costs and strategically hold off on releasing medications until they have exhausted the prior one. For those of you who will argue that this is for safety, I urge you to look at the number of drugs that came to market and were later found to be extremely harmful. What is wrong with publishing data and allowing physicians and patients to decide? Are we too stupid to make those decisions? How long would a drug company be in business if they produced a drug that harmed many people? No one would buy their product and the owner could be held liable in court as well. When was the last time a member of the FDA got sued for approving a drug that was harmful?

Finally, on the issue of care for those who need it and can’t afford it, I bring up the absurd notion of "charity." We are all human beings, and most of us in this line of work have compassion. Personally, I donate a large amount of money to charities every year; charities which I feel do an excellent job. For those of you who think the government is the best charity to handle this endeavor, look at how carefully they handle your money and how efficiently they produce things like new roads and highways. Do you want more "evidence-based" medicine like blood cultures in uncomplicated pneumonia? (hopefully the sarcasm came through in those comments). The free market would do a much better job of caring for sick people than our current socialist system. Wouldn’t it be great PR for a hospital to have an entire charity wing? I think a doctor would acquire many more patients when it became known that he or she spent even one day per month doing free care. Of course, the legal system would have to be drastically revamped in my world, but that is a topic for another time.

When the system you propose requires that you use a word of violence like Tsar, it is time to rethink that system.

Todd Arkava, MD
Nashville, TN

The Glamorous Life

I’m not going to lie, being a physician gives me a certain amount of social clout.

People are often impressed when they find out I am a doctor. It definitely opens doors. The glamour comes from the stereotype. Doctors on television are often portrayed as refined, academic, erudite, sweeping in to save someone at the last minute in dramatic fashion.

Physicians have no doubt capitalized on this image. I must admit, I get great service at the bank, first chair at my barber and approving nods at the school hook up line. I even got a loan for my first house by doing little more than signing my name. The deceived think we are uber-wealthy and smart at everything we do.

I’m hesitant to write more because I don’t want our little ruse to end.

But here is the truth:

Doctors aren’t as rich as you think. We basically work for insurance companies and if you are ever looking for an urban pack of wolves look no further than your HMO.

Exceptions are the Beverly Hills Plastic Surgeons and those who aren’t burdened with filing claims with insurance carriers. These are what we in the medial business call salon doc’s. They really are uber-wealthy (well as least they act like it). These guys are great with a nine iron, have an outstanding over-the-top back hand, and can make you look five years younger and they do take American Express. But as far as physician healers go they couldn’t cure an ear infection. Or they might try to cure an ear infection with Botox or an ear transplant or something.

Doctors are lousy with their money. I have seen many doc’s who think they are day traders. Rupert Murdoch in a lab coat. WRONG!

I once knew a guy once who tried to get me to go "all in" on an insider tip he had from "a friend" about a company that had developed a vaccine for the AIDS virus. To good to be true. The stock opened at 15, lingered to 10 and disappeared at 2. There goes juniors college fund.
Also more than a few doc’s think the IRS is ghost story. (You know how this one ends). I know one doc who lost his house and another who moved to Australia. The IRS is real. Likely because they are souless, heartless creatures physicians get confused by this.

Doctors are good at medicine. That’s it. It’s important, but that's it. Chances are you are good at your job. You get up everyday and go do your best. You are good at what you do because it’s what you know how to do. Your doctor is no different. If I weren’t a physician, I would have a degree in Biology. Not a lot of jobs out there for Biologist. Truth is: your doctor isn’t really qualified to do anything other than be a doctor. I could probably work at the pet store but I'm allergic to cats.

Now don’t get me wrong either. This is no cake walk. The human body is an enormously complicated machine and there are a million things that can go wrong. I made excellent grades in college and med school was a monster. The point I’m making here is that your doctor has paid his or her dues big time. I have a nice income now but I didn’t join the work force until I was thirty and even then had student loans with many zeros.

But it's all gravy now....

Today, an elderly patient came in with a stool impaction. This is when the stool gets so hard that one can’t pass it nature’s way. So someone has to go in and physically dig it out. (It is the only thing I do in the ED that almost makes me puke) There is a lot of protective gear and I get dressed up like an asstronaut going on a space walk. (Misspelling intended) So, next time some one comes to my house and sarcastically says "Oooh look at the rich doctors house", I am going to punch them in the face and reply "Hey, I dug crap out of some one’s butt hole!"

And today, I had another patient who wasn’t breathing well, the family didn’t want me to be to aggressive so instead of putting her on life support we decided to put her on CPAP. CPAP is a device that fits tight over your face like a scuba mask. It’s connected to a tube that basically blows oxygen into your lungs. It’s very much like putting your mouth over a blow dryer on full speed. Anyway, you can’t really talk once you are hooked up, so naturally once I’ve got granny going she decides there is something she really needs to say. Thinking this could be her famous last words, I pull the family close to the bedside, unstrap the device and lean over closely. She mumbles something completely incoherent while spitting on my face. It WAS an accident…..but still, granny spit on my face. Come on!

And lastly today, a prostitute called me "her bitch". Which I know doesn’t even make sense.

That’s 3 things that happened to me TODAY! The irony is that those kinds of things happen all the time. Was any of that glamorous? Hardly. Did I help those 3 patients today? Yeah. I guess so. However, I can absolutely promise you that today, none of those things happened at HMO headquarters...... Don't I wish.