Thursday, November 5, 2009


Working in a county hospital emergency department reminds me everyday that our healthcare system needs reform. I saw a patient the other day that was a sad example of this.

The patient was a hard working handyman who had been recently diagnosed with metastatic cancer. He had noticed a lump on his ribs a month prior, and it was discovered that lump was actually metastatic cancer to his ribs from a gastrointestinal source. He was in the ER for worsening pain. I looked through the computer to see what follow up appointments he had, and I noticed he was to be see in palliative care clinic in the next few weeks. Right then I knew his prognosis. Patients don't go to palliative care for cancer treatment, they go there so their pain can be controlled as the cancer spreads until they die. I talked to him and his wife for a bit, and could tell they still had hope of possible treatment. The past month had been a shock for them, as it would for any of us.

So let me get this straight... an honest, hardworking man who struggled to support his family now has an incurable cancer that was found only after it spread and became noticeable.... YES. We see it all the time. Why wasn't it caught earlier? Only if this patient had a primary doctor who noticed he was having months of weight loss (a classic historical point in cancer patients) or was anemic and needed further workup. If only he had a routine screening colonoscopy for a man of his age. Unfortunately, a lot of the time hard working people who support their family cannot afford health insurance, and in the end they sacrifice.

Health care in this country is the greatest example of the haves versus have-nots. I don't want to paint the picture that people who don't have healthcare are poor and homeless. They have jobs and families but just cannot afford the high cost of medical coverage. I see them every shift in the emergency department. It costs more to take care of a patient who has had a stroke because of untreated chronic hypertension than it is for that patient to have a primary doctor and take daily blood pressure medication. We practice reactive, not preventative medicine. Reactive medicine not only increases health care costs, it hurts people. I am not saying we need a socialist system, but people should not have to choose between medical care and supporting their family. That we should all agree on.

-Nice Doc


Anonymous said...

Are you sure your signature shouldn't be "Naive Doc". You hear what the patients tell you, which may not always include the number of appointments he has missed at the free clinic, the number of cigarettes he has smoked for 28 years, the free colonscopy he didn't bother to sign up for, or the fact that his sister,a CNA, has been nagging him to get to a doctor for 9 months, but what with hunting season and all, he just didn't have the time.

True 100% of the time?? of COURSE not....but most of the time these patients have walked away from every lifeline they have been thrown. Twenty years in various forms of community health, and I could count on the fingers of one hand the folks in this type of situation who asked for and received help, took care of themselves, and died needlessly anyway.

Pattie, RN

R. May said...

Pattie - you are generalizing as much as the other dr is. The truth probably lies somewhere in the middle.

Not to mention the bad tend to stick in our minds.

Anonymous said...

People make bad choices all the time. It is not uncommon for the responsible breadwinner in the family to defer health care for themselves just to take care of the rest of their family. I've seen this many times and it is sad. I hope that whatever kind of health bill that comes out of this political debacle relieve some of this burden.

Anonymous said...

Yes it's important to have healthcare for everyone but the solution is not though a government mandate. How many of the ER patients would really lose weight, stop smoking, stop shooting up, stop doing crack? How many would fill there hydrocodone and not their insulin or "water pill?" Preventative medicine is wonderful but requires proactive patients. Unfortunately, American's want the quick fix. Rather than lose weight, they want a quick pill. Now the government is going to stop paying for patients who return for the same chief complaint? How can we prevent the patient with CHF from returning when he leaves the hospital and doesn't fill his water pill. Instead, he smokes crack and returns with CHF? It clearly illustrates that the democrats are naive and Obama doesn't have a clue. I say we invite Obama to work a shift in a county hospital ED. The answer is not more govenment interference.

Anonymous said...

R.May....truth in advertising, I am NOT a doctor....I am a registered nurse.

Often we are privy to what patients fail to disclose to their physicins, by the way.

Pattie, RN

Fordo said...

Agreed. Change has been a long time coming.

Anonymous said...

We do practice reactive medicine and we also drive up costs with defensive medicine as well. Health care change should also include legal reform. One without the other simply will not work.

Trust us....we're doctors said...

Do you guys think you are giving us new info? No duh there are people who abuse the system, use us for drugs, don't use their resources, don't take care of themselves and we practice defensive medicine. Every country has the people who abuse the system and take horrible care of themselves even though they have medicaid or whatever. It drives me CRAZY too! But they will do that REGARDLESS what system we have. They do it here now. That's not the point.

You can't sacrifice the good people (like the one in this story) for the abusers. Your not going to affect the abusers by not reforming heathcare, and if we dont reform healthcare b/c of the abusers, then you are doing it at the EXPENSE of the good people who need our help. That is wrong and irresponsible. But you let them bother you soooo much you can't see through to the people who will be left behind because of it. It's going to happen regardless, so lets help all we can.

For you to call him naive just makes you a cynical old republican who only wants to help who she seems deed fit. Find another blog to read.

-ER Doc

The Homeless Parrot said...

ER Doc - I agree with Pattie. Nice Doc looked at this patient and made assumptions about why he didn't have health care leading up to the discovery of the metastatic cancer. Nice Doc made assumptions that fit his idea of what is wrong with health care in this country. The truth is - we'll never know why this one, particular patient didn't receive medical attention for his weight loss.

Health care in this country is in a bad mess, no doubt. I 100% agree with that. I think torte reform is the FIRST place to start. This will stop the practice of CYA medicine and drive down costs b/c it will eliminate unnecessary testing.

Calling Pattie RN an old cynical Republican is rude. I'm not a Republican, but I certainly don't endorse a government health care take-over. She has very valid, important points.

Anonymous said...

You are also naive to believe that providing government health care could somehow prevent his cancer. I don't think it was his lack of insurance that prevented him from seeing a doctor because we all know anyone can walk into an ED for free health care. In addition, it's naive to believe that government run health care will prevent diseases. It still requires people to be proactive and go see their doctor. The solution is not government health care. There are other options that should be explored before allowing big government to interfer with medicine.

Anonymous said...

Ms. Parrot...thank you for your kind words.

For the record, I am a Libertarian, not a Republican. But most of all, I am a realist. As I stated in my original post, I have seen well over three thousand community patients in my time, and fewer than five were "innocent victims" who were dealt a horrible and unfair hand in the game of life, with circumstances they could not have forseen, prevented, controlled or managed in a more proactive fashion.

And ER Doc--assuming that you are not in fact a Serbian goat-herder-I can only conclude that you are VERY new at this game or have a political axe to grind. I save my sympathy for the truly downtrodden, who are few and far between. With apologies to Dr. Phil, when you choose your life choices and priorities, you also choose the subsequent consequences.

Pattie, RN

Trust Us...we're doctors said...

"we all know anyone can walk into an ED for free health care"

I am an ER doctor...going to the ER is not free care! It doesn't constitute preventative care nor continual care. We treat acute stuff. Its not routine medicine.

And I practice in a state that has Tort reform. It helps, but it is definitely not the end all be all. We still practice very defensive medicine. And the medical costs of our state are still very high. The main difference is that we have more doctors coming to our state b/c our malpractice insurance rates are cheaper. Still practice defensive medicine though.

And read her comments. Saying that MOST people walked away from free colonscopy's, various forms of community heath, and every lifeline they are thrown is flat out wrong and making a huge assumption. I didn't have insurance until after residency. My parents never did. Made too much for medicaid and couldn't afford private. Some communities have stuff to help, most don't. Then to say most of the people who are in communities that help don't go to get that help..... thats just going to far.

And how do you all know nice doc made assumptions?? he spent a lot of time with that patient and went the extra mile...and I am willing to bet he got to know what his circumstances were.

I saw a patient last week with a mass on his neck the size of 2 softballs. Just kept working to save up money for the FNA he needed to diagnosis it. Paid out of pocket for the primary docs that kept saying he needed a biopsy. Well when he could finally afford the biopsy 2 years later guess what?? It was too damn late!. I am tired of good people being left out to dry. Maybe that makes me a bleeding heart liberal...I dont care. But the abusers are going to do the same old thing no matter what, and Im not going to sit back and let it be at the expense of people who need help. I didn't go into medicine to help just people who can afford it, and I'm sick and tired not being able to really help ALL the people that need it.

-ER Doc

Trust us...we're doctors said...

Re Patty:

..."I have seen well over three thousand community patients in my time, and fewer than five were "innocent victims" who were dealt a horrible and unfair hand in the game of life, with circumstances they could not have forseen, prevented, controlled or managed in a more proactive fashion"

Really...only 3 thousand?? and only 5 innocent victims? You must be living in the burbs. I saw 5 in my last shift in the county ER.

Maybe you need to see more patients. I work 15 shifts a month, see about 35 patients a shift. Thats 15x35x12 months = 6,300 patients a year. You have see 3000 in your lonnng career. You need to go to a busy place. Try a county hospital. Then look some real people in the eye and tell them you can't help them.

-ER Doc

Anonymous said...

But government run health care isn't the solution! It's not going to fix the problem and it's wrong to assume that it will. Health care needs reformed but not via more government interference. There are other solutions ER Doc you sound like a whinning baby. Take off the diapers and get your pacifier out of your mouth. The guy who needed the biopsy just needed to walk into a county hospital- anywhere in the country. It would have been biopsied. I'm going to rename you Doc Pacifer b/c you are either really young and naive or a true whiny baby.

Anonymous said...

Your looong career is what 2 to 3 years? I've stared at "real" patients for 20 years and know that government health care isn't the solution. How many patients have your treated in a your two years? I've been doing this for 20and have seen over a hundred thousand patients. I have worked in the "burps" and trained in a country health system. I was around to see the old system change when HMOs came around. Based on my years of experience, I can tell you that government in health care is a BAD idea. Let doctors and nurses figure out a solution- not a bunch of lawyers and bleeding heart democrats.

Trust us... We're doctors said...

Did I propose govt run healthcare? No. and no he couldn't walk into a county hospital and have it done (btw that's basically saying the govt would do it). He would go to the ER, the ER would have said it's not an emergency procedure and refer him out to get it done. He would then go to the appointment and not be able to get it done bc guess what he would have to pay first.

And if advocating for my patients makes me whiny that's cool with me.

-ER Doc

Anonymous said...

I work in one of the largest county hospital in the country. Yes, if he walked into our ER and his problem is not an emergency,he will be referred to our clinic where he will then have access to the specialist he need to get his biopsy done. I don't know what county hospital you work ER Doc but your system has to change so that patients like this one can be taken cared of. Your hospital policy is the one that is broken..

Anonymous said...

He would have access to the clinic and the specialist, but if you don't meet criteria for the county insuranthey will bill the hell out of you. County hospitals charge people too and will drive you to bankrupsy too. I think if county hospitals were the answer then healthcare would not need to be reformed the way it does

Maria said...

You people talking down to the docs should be ashamed of yourselves. Doctors notoriously want one thing, money. Here you have 2 drs fighting for the poor and look how you speak and think. We need more of them. Its their ideals that made them into healers in the first place. I might be an old lady, but I know genuine when I see it.

Anonymous said...


I work in a cancer center and I see folks without insurance all the time...

If you see a pt who is "saving up" for an FNA you're seeing someone who has been sadly misinformed. I get way more expensive stuff comped all the time. Just today it was a PET/CT scan. Yup... a freebee! Look around, the cash or the programs are already there...

Trust us....we're doctors said...

Okay... I will preface this by admitting that I've had a few beers tonight.

If what I say is too out of line, then I trust my colleagues to delete/edit this.

This is to all you nurses/RNs/whatevers out there. Yeah I apprecaiate what you do. Patients love you. You are their friends, they share their lives with you. However, you have no liability/culpabilily/responsibility to these patients.

When they are pissed off because of poor medical care, who do they sue? Not you. Why? You have no insurance. You are nothing.

If you want to make rules, be the boss, etc, go to medical school. If you want to have real responsibility go to med school. Whatever happens on my unit, I am responsible for. Patients will always pit you against us. You are in a great position, with your medical knowledge and TOTAL lack of liability.

So when doctors have advice about medical reform/policies, I have some advice.

1. Wash your pussies, i.e. go buy some douchebags and stop whining,

2. Work 7-7

3. go home and kiss your families and be happy.

4. don't tell me how to do my job.

- psych doc

Trust us....we're doctors said...

5. Don't worry about $150 K in student loans

6. Don't worry about malpractice insurance.

- psych doc

Anonymous said...

Dear Trust us and/or Sebian goat herder....

Thank you for clarifying your state of intoxication..drinking and blogging is rarely a great idea.

Thank you also for exhibiiting your total ignorance of the role of the RN in the health care delivery system. We are "nothing" who have "no responsibility" for our patients and "can't be sued"??? You, sir, are an asshole, and I hope the nurses who work with you find out who you are. I'd LOVE to see you handle a shift without "nothing" nurses.

Nice ad hominem argument when you can't come up with anything else. Classy, too!

And the pudenal references seal the deal...I bow to your superior intelligence!

Come back and chat when you are (A) sober and (B) have been shaving for more than three or four years. Meanwhile, the rest of us will discuss policy issues in health care and other boring grown-up stuff.

Pattie (with an IE), RN

Anonymous said...

I agree with you on reactive versus proactive approaches. On a definitely smaller scale, I have a strong family history of diabetes, and the only way I can get help in preventing it is to research on the internet and hope that I am doing the right things. My insurance won't cover visits to the diabetes center or a nutritionist to help me manage my weight problems. I guess I can go see these people when I do get diabetes. :/

Anonymous said...

You should research on how to get outside and run or exercise. Then, google "eating healthy" and it will pop up no hamburgers or fries and more fruit. You don't need a nutritionist or doctor to tell you that.

DreamingTree said...

Quite the conversation going on here, Docs. I admire your empathy for your patients, and agree wholeheartedly that health care reform is a necessity. All of us may have different opinions on what that should be (or shouldn't be), but we're all going to have to accept the final verdict. I just hope that it is something that helps more people.

I've seen plenty of patients who should have taken better care of themselves. They should have quit smoking, followed their diet, and taken their meds everyday as ordered. For example, I just worked with a woman who quit testing her blood sugar, taking her insulin, and following her diet for a year. Ridiculous, right? She had gone to an appointment, felt embarrassed by comments she overheard, and shut down. Tough luck, huh? What she needed when I met her was someone to accept what had happened, and help her find a solution to move forward. I've helped her turn this problem around because I could do so without judgment. Taking time to listen without judgment helps. Don't misunderstand me, though -- I've met the folks who aren't ready for this help & would rather scam the system. I know they're real.

Psych Doc -- don't drink & blog. Don't lump all nurses together, and don't underestimate the liability we face. If a doctor writes a stupid/unsafe order and I implement it, I could lose my license. In the short time I've been a nurse, I've caught many errors & saved the doctor's ass. Being that my first career was as a psychologist, I'll just assume that you got caught up in the argument and lashed out. No Freudian analysis from me... ;-)

R. May said...

Yes Pattie I was aware that you are a RN, to forgive me for not being more clear.

My point remains the same. Your patients and the doctors patients are a small sample of America. You have your opinion that you have formed through caring for your patients and so has ER Doc.

This is whats called anecdotal evidence as I would expect people in the medical field to know. It means nothing.

Name calling and insulting others for their opinions sure as shit isn't going help anything.

There's a lot of anecdotal evidence floating arround. There's a lot of fearmongering and insults floating around. But there's a distinct lack of evidence.

Trust us....we're doctors said...

I admit that I crossed some lines with my post a few days ago.

The point I was trying to make is this. This is a story about a guy with cancer. Cancer is going to kill him. It doesn't really matter how he got it, why he got it, etc.

What matters to him is that he found out too late. Too many times I have heard patients that are going to sue their former doctors because they didn't find it sooner.

They never say, "I'm gonna sue the nurse who checked my vitals at that office visit 3 years ago when my cancer was probably only Stage I."

So please don't come on here telling us that we're naive, or need more years of shaving, etc.

And for the record, I have been shaving for at least 20 years. I did have a career before med school, so I have a broader worldview that you may think.

I'm sure that as long as Pattie's been a nurse, she has probably gone through "the change" and has probably been shaving her facial hair for 3-4 years herself.

Please accept this as my formal apology, and I won't drink and blog (as much) anymore. Most of my stories are posted in some stage of inebriation. It helps me have empathy for my patients.

-Psych Doc

DreamingTree said...

Psych Doc -- I agree wholeheartedly with the point you are trying to make. However...your next to last paragraph weakened your apology and explanation. And, I'm hoping that you were joking about your usual blogging state. Alcohol brings empathy?

Anonymous said...

Never try to teach a pig to sing. it wastes your time and annoys the pig.

And psyche doc...I don't work in medicine, but you seem to have a drinking problem. buddy. I think you need to stop insulting people on the internet and focus on your problems.

Not to mention, Psyche docs have a medi problem right now when it comes to their own mental health.

Jack, USMC (ret.)

Trust us....we're doctors said...

Look people, I am over-exaggerating. I usually post on weekends after I've had a couple of beers, otherwise I don't like to sit down long enough to post.

I appreciate the last Anonymous post about the mental health of psychiatrists. At least I have this blog to vent. Maybe if the Fort Hood guy had a blog, he could have released some anger.

Or maybe he did. Seems like our own government was onto the guy but didn't do anything. Why not? Don't blame psychiatrists, look in your own USMC/CIA mirror. The Fort Hood guy's problems had much more to do with his religious beliefs than his profession.

-Psych Doc

R. May said...

Psych Doc is officially my new favorite. Pretty tough to unseat Nurse K but you managed.

Anonymous said...

Hey-Jack here again.

Psyche Doc....until I became a friend of Bill W., I was sure my drinking wasn't a real problem, either.

Buddy, you need to take a look at how much booze is fueling your anger....and after wife number 3, I can tell you have a real issue with women, too. Fix yourself before you fix anyone else.

Trust us....we're doctors said...

The only thing fueling my anger is people calling doctors naive just because we're in residency. We all bring different life experiences to the table. And just because somebody's old, or been doing this a long time doesn't mean that they are smarter or right.

Call it denial if you want, but I do not have a drinking problem. It is not illegal to drink and blog. I had enough insight to preface that post with the statement of my degree of being intoxicated.

If people want to be anonymous and condescending to my colleagues and myself on a blog in the internet age, then you should be prepared to be responded to likewise.

I did take it too far. But if you can dish it out, you better be able to take it. Like my momma used to say. She also said life is like a box of chocolates. That night you all got a doctor that is tired of "hearing" from entitled, know-it-all nurses on medical blogs.

I have nothing against nurses or the ones that I work with. Because nobody would say this stuff to my face, because that it is inappropriate to do so.

The internet has allowed us to have a double standard of ethics and decency b/c we can all be anonymous. Don't be upset because I crossed some imaginary line.

-psych doc

Trust us....we're doctors said...

Amen psych doc!

And for the record psych doc had a lonnng career before medicine. So did doc sensitive (who by the way is very insensitive it was meant to be sarcastic). They are what you call non traditional medical practitioners. So they aren't young blah blah... They have insight. I, though, am just a young asshole.

-ER Doc

DreamingTree said...

As a second career nurse, I agree wholeheartedly. And, I like a psych person who isn't too PC (takes one to know one).

Anonymous said...

What some commenters fail to realize is that, sure, health care reform might save some deserving poor people who have developed cancer or precancerous lesions -- but that would come at the risk of saving some undeserving people, who are lazy, stupid, noncompliant, or have bad habits. It's better to let innocent people die of preventable/treatable cancer than to run the risk of accidentally applying resources to the care of somebody whose morals we don't approve of. This is America, after all! Government of the puritans, for the puritans, by the puritans.