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.

Grandma is coming over for Thanksgiving.

Working Holidays

This year I worked Thanksgiving. It’s always busy and there are usually a few really sick patients but you can also count on the usual players. Here is a patient that every ER doc dreads seeing on the holidays.

Chief Complaint: Grandma doesn’t look right/ not eating/ feels weak/ vomited.

This one is guaranteed. Every Thanksgiving the extended family gets together and many haven’t seen granny since last Christmas. Spurned by guilt, the “love contest” begins. It starts when Grandma is abducted from her nursing home or assisted living facility. The doting and concern begins. Granny has been force fed Turkey and dressing, potatoes, a mystery casserole and 5 pieces of cake. She also takes a shoe box full of medicines. Ultimately grandma vomits and this event sets off a 5 bell alarm. The “good” children spring into action. The best children are doing the Heimlich, knocking off granny’s wig. Others are preparing for CPR (no one wants the mouth to mouth), while others are calling EMS. Assaulted, granny doesn’t know what the hell is going on. My favorite family members are the ones who decide to just have another Egg Nog and stay out of the way. EMS arrives and brings granny to the ER with a convoy of mini-vans in tow.

The nurses arrive in the room and check things out. This usually means getting grandma alone, getting her wig back on, a shot of Pepto-Bismol and a glass of water. Everything is fine. Now the hard part: convincing the family.

ER doctor trick: Find the alpha male. This is usually the highest functioning member of the family, the one who knows granny the best. This is my best shot at diffusing the drama. This is also one of the reasons why we limit each patient to only two visitors. We typically run a few blood tests and an ECG; chances are good these are going to be baseline values for the 85 year old.
Now time for discharge, this is where I get the dirty looks. Aghast the distant family cannot believe we are sending MeeMaw away. She’s old and she vomited for God’s sake! She needs a stomach transplant! This is not what happens on television! They are sure she is having a heart attack or a stroke or some other medical catastrophe. Truth is she’s not. The problem is I can’t guarantee that she won’t have any one of these next week. People love the guarantee. A cruel fact of life: There are no guarantees in medicine. “All the screening test look okay”, I tell the family, “Let’s get her back to her normal routine and I think she will be alright.” The alpha family member understands but smartly keeps quiet. He or she knows better, let me be the bad guy. The lost sheep of the family usually chimes in with this thinly veiled threat “Well she better be alright!” Checkmate.

Knowing I can’t win here, I grab the next chart in the rack.
Chief Complaint: Turkey baster is stuck somewhere it doesn’t belong.
Nice.

Patient Tip: (also one of Doctor Gibson’s ways to save health care). This one has to do with grandma and her shoebox full of medicines.

If you are over 85 years old, stop taking your cholesterol medicine.
WHAT! You read that right. If you have reached the extremely golden years you can lay off the cholesterol meds. Chances are they are costing you over 50 bucks a month and what are we really doing here? If you are 85, I say you have earned the right to eat and drink whatever you want. If you just want dessert, fine. If you just want to eat 5 desserts, fine. Want to take up smoking? Fine. You have beaten the average, you’re 85! You won. So take that 50 bucks a month and buy yourself a cheesecake. You’ll like that better anyway.