My Problems with the Business of Medicine

December 26, 2006

My family reads what I write here and I struggle sometimes with that knowledge. Exactly how free am I to write stupid things and reveal embarrassing secrets? I handle this in the style of our times: denial. Sometimes, though, I am reminded that they are out there in Al Gore’s internet when they send me their opinions about my writing. After receiving the following email, I realized that instead of writing about a small thought that belongs in a larger argument, I should have just written the whole thing.

Where did you get the idea that Universal Health Care meant that the Doctor was not compensated for his services? My understanding is that you (the Doctor) would be compensated for your services, at a possibly reduced rate the same as Medicare and Medicaid compensate the Doctors. While I know this is not the full amount, you are under no obligation to accept the patient in the first place. There are Doctors all over this country that do not accept Medicare patients for this exact reason. However, if you hope to have Hospital privileges, the Hospital’s policy will trump yours.

Just curious. Mom.
For some background, she is responding to my post No Right to Health Care. I wrote it because the more I read about Medicare, Medicaid, and the “funding” of physician services (hat tips to KevinMD) the more frustrated I get. It’s been happening a lot lately. It’s the frustration of having to enter a system that (in my mind) shouldn’t be allowed to function the way that it does. Supply and Demand curveI’m a strong believer in markets. I believe in the meeting of supply, demand, and value complete with a fulminate crush on Dagny Taggart. These days, I’m frustrated over that fact that the value of the service that a physician provides is not strongly coupled to what he can charge, and instead his recourse is to make his salary through volume. I started writing this during exams, so in that spirit I offer you a medico-economic vignette. Read the rest of this entry »

No Right to Health Care

December 9, 2006

I’ve been thinking a lot about health care and the mess I’m about to inherit in the next couple of years as I earn my MD and enter Residency training.  As a student of medical blogs, it’s hard to be keep my head in the sand about such things as they clearly occupy a good deal of the discussions.  So right now I’m addressing the perceived “right to health care.”

I’m against it and here is why.

When we think of our rights, we often think about the Bill of Rights and the Amendments.  The right to bear arms, the protection from unreasonable search, the right to peaceful assembly and the right of free speech.  The common thread in these rights is that they

  • cost nothing to maintain or respect
  • requires other persons to refrain from violating it in order to fulfill it

These are referred to as Negative rights.  If you leave me alone and I leave you alone, we have maintained these rights and violated nothing.  Now if you look at the proposed Right to Health Care, you will notice that this fails both of these standards.  It instead

  • costs a great deal
  • requires other persons to perform a service in order to fulfill it

These are referred to as Positive rights.  Under this right, if I fail to provide you the service of Health Care, I am violating your right to my service.  And now we reach the crux of my argument:

I do not recognize your right to my service.  I instead take this time to remind you of Section 1 of the Thirteenth Amendment which states:

Neither slavery nor involuntary servitude, except as a punishment for crime whereof the party shall have been duly convicted, shall exist within the United States, or any place subject to their jurisdiction.

Dramatic, no?  The Thirteenth Amendment is a perfect example of a negative right and I find it defensible as such.   If you’d like a more contemporary quote, you need go no further than Ayn Rand:

“I swear by my life, and my love of it, that I will never live for the sake of another man, nor ask another man to live for mine.”

I think that the goal of providing Universal Health Care ffor the United States is an admirable one, but I object to the justification used and the way people want to implement it.  But that’s for another post.  In the meantime, if a proponent of Universal Health Care cannot successfully address my simple argument above, then that person needs to seriously reevaluate their support of the idea and their attacks against physicians (both present and future) that object to it.

Though I am training to provide a service, that does not make me your servant.

Wikipedia has a great entry on Positive and Negative rights.

Grand Rounds, edited.

November 16, 2006

Edited essay

This last week I received over 60 submissions for Grand Rounds and included 26. This decision came after sharing some Carl Jungian vibes with Kim at Emergiblog and receiving the blessing of Nick Genes of Blogborygmi. Kim has since received a great deal of attention for her critique of the swelling Grand Rounds. According to the comments, the idea’s a hit and things may change. Next week’s host, Dr. Anonymous, has already thrown down the gauntlet:

This may be my last time hosting Grand Rounds, and I may get a lot of flack (and all my future submissions may be rejected). But, hey, I’m the editor and I’m deciding what’s in and what’s out this week. Being included in Grand Rounds is not an entitlement; it’s not a right; it’s a privilege.

Whether you agree or disagree with me, my vision next week is to put the best medical STORIES (ie – first hand anedcotes) out there for people to read.

As a host I had plenty of resources and support but as an editor I was unsure about what I could and couldn’t ask from fellow bloggers. I’m offering this post as an example of how I approached the problem of writing letters to the authors and helped a few posts that were almost there get over the edge. Accepted, rejected or edited, I sent over 80 emails and received only one response that was not enthusiastic or understanding. From this, I have to assume that people are open to the idea of constructive criticism.

If you’re an author, please don’t be put off by this. As Susan pointed out to me, “editing is also an act of love, and also a compliment on the part of the editor who spent so much time on your work.” I couldn’t have said it better and hope it’s a sentiment that every author who’s asked for edits takes to heart.

Permission was granted from Susan and the Angry Medic to show the emails below. Read the rest of this entry »

Red State Blue State

November 9, 2006

The elections are over and the vitrol is seeping back into the gutters where it belongs. I like to imagine that there is a majority out there that is tired of the oversimplification of complex problems and hopes for a future where Americans don’t shy away from being challenged on their entrenched beliefs. I think that both Democrats and Republicans are guilty of this, and that in referring to candidates as either Democrat or Republican, I am guilty of this. Clearly, words are failing me.

So I’m going to switch to an image. Read the rest of this entry »

Med School Metaphor: Pancakes Every Morning

November 1, 2006

Pancakes Every MorningI have a lot to learn. By Friday, anyway. I have a Pharmacology exam followed by a Pathophysiology exam this coming Monday. Once again, I find myself behind. It’s the funny kind of behind where you look at the stack of notes on your desk (2″ of one, 3″ of the other) and sort of chuckle. “Ha. This is going to be funny.” Cue despair.

Looking at it now, I’m tempted to start the passive bragging of impossible odds. “You have no idea how hard it is,” I’d say. “Medical school is like trying to take a drink from a fire hose,” I’d brag.

And that’s total bullshit. Read the rest of this entry »

Lazy attack on atheism

October 27, 2006

The God Delusion

There is a new book out by Richard Dawkins called “The God Delusion.” His mission is to bring the discussion of atheism out in the open and to make a case for it and against the belief in God. has a great write-up of Dawkins’ work and his new book. Readers of the medical blogosphere may notice that atheism has been popping up lately. Dr. Herbert wrote a piece about an atheist patient of his. The Neonatal Doc wonders what is said at an atheist funeral. As an atheist, I’m sensitive to pieces like these because I wonder exactly what I’m going to do when caring, not for the atheist, but for the religious. What am I going to say when a family asks me “Do you pray, doctor?” or “Will you say a prayer for my loved one?” Read the rest of this entry »

An ‘A’ I didn’t earn

September 27, 2006

a-big.jpgI don’t really like the way I feel right now. Before taking my exams, I’d heard that the class historically does poorly on these tests and this makes the cut-off for an A much lower. Knowing this, I decided not to push myself and to be comfortable with a lesser score. I got exactly what I asked for: two As just above the new cut-offs.


I’m not proud of what I’ve done and don’t feel much for celebrating. Worse, I think I saw this coming.

When they start us out in medicine, there’s a quote that gets thrown around to make each of us a little less nervous about our grades and a little more smug about getting by. Vitum Medicinus drew my attention to it once again:

Q: What do you call someone who graduated at the bottom of their med school class?
A: Doctor.

It’s funny, and it’s not. Read the rest of this entry »

SVD Frustration

September 22, 2006

frustration with SVDI’m so fucking frustrated right now.

At SGU, after any exam, the scantrons are collected and those students wishing to may leave. Students may choose to remain to be passed the answer key. They then have a half hour to look over their own answers. This system is so important to me as a student because it:

1) allows me to catch things I’ve missed that may be important

2) catch mis-keyed items

3) write challenges to questions that are poorly worded or have more than one correct answer.

All of this is important when you consider that everyone (profs included) make mistakes and that many of our professors are foreign-born, so the use of English sometimes does not sync correctly.

Why you would screw up a system that works is beyond me. Read the rest of this entry »

This is what I’m talking about

September 13, 2006

The other day I had some sour grapes over my experiences in Psych. My feeling was disappointment over the disconnect between what I read from folks in the field and what I experience clinically. For those that don’t get the chance to surf as much, The White Coat Rock has two excellent posts today:

Drugs, Hugs, Hags, and Has-Beens:

“There is nothing lamer than people who live a sort of drug-filled, hedonistic lifestyle, then come to see the light and become crusaders against what they once enjoyed. You find this occassionally, former hippies or scenesters who suddenly find religion and then go around telling everyone ‘Yeah, I did this stuff, and really enjoyed it too. But I realize now it was wrong, and you all shouldn’t do what I did.’ Hey, you had your fun, so keep your fuckin’ mouth shut and let others find their own paths.

That is my brand of anarchism: don’t let anyone tell you what the limits of your experiences on Earth should be. It’s your right to fuck up. Just don’t whine so much if you find yourself down and out.”

Personality, or Lack Thereof:

“I’ve been in a pissy mood recently. Inexplicable. Need to remember to leave my knife at home. Can’t afford to get into any knife-fights.

Anyway, I’ve been thinking about personality disorders recently, since we talk about that a lot on the psych wards. I don’t like the idea, never have. As far as I can tell, the personality disorders were invented by psychoanalysts who got frustrated by patients they couldn’t pin on a discrete diagnosis on, but who had enough indiosyncrasies for the therapist to suspect they ‘just weren’t right.'”

The Bell Curve

September 12, 2006

MD teaching bell curve Those outside of medicine, I want you to know this: doctors are doctors because they know medicine. They are not doctors because they are great teachers. And who teaches future doctors? Doctors do. For students looking to learn, it’s the lottery of the bell curve. Will today’s doctor also be a great teacher, an ok one, or confusing? Most of us will end up drawing in the middle. This week it feels like I’m on the losing tail.

To the clinical tutors I have had this past week, this is my open letter to you: Read the rest of this entry »