Obama: It's OK to borrow to pay for health care

[kbordson 8]

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>These days I think the right thing to do would be also not pay and let
>the system collapse under its own incompotence and mismanagement.

I'm not sure letting hospitals collapse and doctors go bankrupt is the best way forward.

>I agree emergency rooms have to treat emergencies. What they don't
>have to do is treat Bobby's sniffles.

Exactly. Have an urgent care clinic that's free to Bobby's parents. There's a doctor there who says "your kid has the sniffles. Here's some aspirin. NEXT!" He takes care of 70 patients a day - that's 70 patients that aren't clogging up ER's with the sniffles.

Then Bobby gets Reyes Syndrome from the ASA and has to go to the ER... Now a VERY SICK lil Bobby.... maybe even a dying Bobby

And the parents then go to the lawyers.

How is the above clinic different from any other HMO PCP or family practice?

You're on the inside, how do you propose getting the non emergency cases out of the ER?

A change in mentality of THE PEOPLE. You can go to acute care clinics without insurance.

Here in Kansas City, we have multiple services
Swope

Childrens Mercy

and others that I don't want to google.

Both of those have payment option plans.

As a parent, one should acknowledge that having children comes with costs. Just cuz you got knocked up doesn't mean that society should step up just because. NOW... there are some situations that public assistance IS important.... but if you have the ability to take Bobby to Childrens Mercy for a clinic appointment (even if it might cost you $25 or $50), why would you think "I'm just gonna take him to the ER"?

But... MANY do.

The culture change is very unlikely to happen....

But that is the preferred solution.

[Bolas 5]

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>These days I think the right thing to do would be also not pay and let
>the system collapse under its own incompotence and mismanagement.

I'm not sure letting hospitals collapse and doctors go bankrupt is the best way forward.

>I agree emergency rooms have to treat emergencies. What they don't
>have to do is treat Bobby's sniffles.

Exactly. Have an urgent care clinic that's free to Bobby's parents. There's a doctor there who says "your kid has the sniffles. Here's some aspirin. NEXT!" He takes care of 70 patients a day - that's 70 patients that aren't clogging up ER's with the sniffles.

Then Bobby gets Reyes Syndrome from the ASA and has to go to the ER... Now a VERY SICK lil Bobby.... maybe even a dying Bobby

And the parents then go to the lawyers.

How is the above clinic different from any other HMO PCP or family practice?

You're on the inside, how do you propose getting the non emergency cases out of the ER?

A change in mentality of THE PEOPLE. You can go to acute care clinics without insurance.

Here in Kansas City, we have multiple services
Swope

Childrens Mercy

and others that I don't want to google.

Both of those have payment option plans.

As a parent, one should acknowledge that having children comes with costs. Just cuz you got knocked up doesn't mean that society should step up just because. NOW... there are some situations that public assistance IS important.... but if you have the ability to take Bobby to Childrens Mercy for a clinic appointment (even if it might cost you $25 or $50), why would you think "I'm just gonna take him to the ER"?

But... MANY do.

The culture change is very unlikely to happen....

But that is the preferred solution.

Hence why since there are other free and low cost options, the super expensive one should be eliminated.

It's modern society, if your processes are based on educated people doing the "right" fair honest thing, you're already hosed. People are going to do what's easy and/or free. Knowing this, make the choice you want them to use the most enticing and/or degrade or eliminate the other ones.

It's kinda the business equivalent of creating a super complicated process that requires lots of training and maybe even time using to figure it out. Training cuts and turnover are gonna kill ya every time...

Stupidity if left untreated is self-correcting
If ya can't be good, look good, if that fails, make 'em laugh.

[lawrocket 3]

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You're on the inside, how do you propose getting the non emergency cases out of the ER?

Quit making the ER free for all is a good start. "I think I might have broken my ankle and I'm not insured. Where can I get treated? Everybody knows that they HAVE to treat me in the ER.

"Dammit. All these people here. This better not take long.
<16 hours later to the triage nurse>

"WHAT THE HELL IS TAKING SO LONG? I had no idea it would take this long! I've got an appointment to install my bigscreen in an hour and a doctor hasn't seen me. They'll charge me $150 if I don't cancel in the next 5 minutes and my iPhone is dead! What the hell is wrong with you people?!"

"It's these damned Mexicans abusing the system..."

My wife is hotter than your wife.

[lawrocket 3]

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Interesting article on the costs of the Obama plan here.

Amazingly, the Congressional Budget Office estimates that coverage for 16 million of the currently uncovered 51 million people (roughly 1/3 of those currently uninsured) will cost a trillion dollars. What would it cost to cover the other 2/3rds?

A trillion dollars over 10 years? I call bullshit.

Medicare spends a trillion every two years. Governments spend a trillion every year on healthcare.

And it'll only be $100 billion per year to insure a third of the uninsured? Right...

My wife is hotter than your wife.

[DanG 1]

There was a fascinating article in the New Yorker recently about culture change beeing necessary to save US healthcare. The fascinating part is that the culture needing change is the doctors', not the patients. The article (long but very good) is here: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

My short synopsis: doctors in many areas have created business structures and institutions where they are rewarded by the quantity of care they provide, not the quality. The author contrasts the most expensive region in the country (McAllen, TX) with other similarly sized regions, and finds that the quantity of care (tests, specialists visits, surgeries, etc) being provided in McAllen is much higher than other areas, but the quality of care is no better. He describes the culture of the doctors working in McAllen and other high cost areas as one driven by a strong profit motive instead of a desire to treat and heal patients. To bring down healthcare costs in the US, he suggests we need to find ways to compensate doctors other than by how many tests and labs they order. One suggestion is to pay doctors a salary instead of paying them by the procedure. This method is one of the things that sets the Mayo clinic apart from others. The doctors are free to treat patients as their condition requires without woorying about their personal bottom line.

- Dan G

[lawrocket 3]

Salaries can be good things. They are most useful for employees.

Business owners are different. What would you suggest businesses do with profits?

On the other hand, I can also tell you that business owners often cannot pay themselves salaries. My wife and I have on several occassions been the lowest paid employees of our business.

Hiring a new doctor for $120k per year is a valid option but who does the paying?

The last thing I want to see are non-physicians running or owning medical practices or taking away any profit motive.

My wife is hotter than your wife.

[DanG 1]

I suggest you read the article. The author does a much better job of explaining the situation than I can.

That being said, no one is implying that a profit is a bad thing. The problem comes when doctors place the desire for profit over the needs of the patient. One example given in the article is how doctors are paid to be consultants to hospitals and clinics and basically being bribed (legally) to send their patients to the same facilities for unnecessary work.

The problem is not with small practice physicians, it only becomes a problem when those physicians become interwoven into a network of clinics, labs, and hospitals who all profit by patients rotating through their facilitiies whether they need the care or not.

The author (who is a physician) makes the point that it doesn't really matter who writes the checks (the patient, private insurance, or the government) as long as the decisions for what care to provide are being decided based on the botttom line and not the health of the patient.

- Dan G

[Bolas 5]

This is where the health insurance company oversight comes in to play and is a balance as that directly effects their profits.

If they think one health organization over examines people and orders unnecessary tests, they can switch to another or threaten to.

Stupidity if left untreated is self-correcting
If ya can't be good, look good, if that fails, make 'em laugh.

[billvon 3,009]

>Then Bobby gets Reyes Syndrome from the ASA and has to go to the ER...
>Now a VERY SICK lil Bobby.... maybe even a dying Bobby

>And the parents then go to the lawyers.

Yep. Just like now. That's another issue we have to work on.

[kelpdiver 2]

I'm not going to be able to read that till off hours - work only allows for snippets of such distraction.

The problem with the salary model stems from the other problem with doctors - they work too many hours and they leave medical school with debts that could buy a nice house in most of the country. This comes from the deliberate restriction in the supply of medical school graduates. If you don't change that, you can't switch to a salary model that doesn't reward doctors to some extent for quantity of work. Otherwise, will they be like the lower 50% of Kaiser docs?

when I had my shoulder operated on (a friday afternoon), my doctor called me twice over the weekend to check my status. Since Friday was a full day of procedures, I expect that was at least a half dozen calls each day, and figure at least a couple required some further discussion and action. It's a busy life for him. My spring was like that, and I'm still trying to feel normal again.

[TomAiello 26]

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There was a fascinating article in the New Yorker

Post #16

-- Tom Aiello

Tom@SnakeRiverBASE.com
SnakeRiverBASE.com

[lawrocket 3]

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The problem comes when doctors place the desire for profit over the needs of the patient. One example given in the article is how doctors are paid to be consultants to hospitals and clinics and basically being bribed (legally) to send their patients to the same facilities for unnecessary work.

There are a couple of pragmatic issues that I am unsure that you recognize. First, referral networks are wonderful things. I have my own - other attorneys whom I know and trust. If there is an issue that I do not handle (like bankruptcy) I have a couple of attorneys that I refer this business. These guys don't do family law or real estate. I am on their list.

Hell, I have attorneys I know and trust that I refer opposing parties to! Not because I know I can "win" but because they are competent, professional, and easy to work with - thus saving our clients money and saving each other stress.

Referrals are a business tool, but they are also in the clients' best interest. I can get sued if I refer them to a moron, and I won't let that happen.

Second - clinics, hospitals, labs, etc., are parts of that network. Health care is like a pencil - no one person can make a pencil. You would have to start by chopping down a tree - for that you'd need an axe made by someone else. That's just for starters.

Labs provide the physicians with subjective information on the patients. Etc.

The article indicates that McAllen hospitals do a lot more tests. However, there was a really telling moment in the article on Page 5:

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I remember when my wife brought our infant son Walker to visit his grandparents in Virginia, and he took a terrifying fall down a set of stairs. They drove him to the local community hospital in Alexandria. A CT scan showed that he had a tiny subdural hematoma—a small area of bleeding in the brain. During ten hours of observation, though, he was fine—eating, drinking, completely alert. I was a surgery resident then and had seen many cases like his. We observed each child in intensive care for at least twenty-four hours and got a repeat CT scan. That was how I’d been trained. But the doctor in Alexandria was going to send Walker home. That was how he’d been trained. Suppose things change for the worse? I asked him. It’s extremely unlikely, he said, and if anything changed Walker could always be brought back. I bullied the doctor into admitting him anyway. The next day, the scan and the patient were fine. And, looking in the textbooks, I learned that the doctor was right. Walker could have been managed safely either way.

This identified a number of problems. First, patients and their parents can often bully a physician into admitting a patient. Costs go up. Is this something cultural that happens more in certain places than others?

And a second thing - how many people here are aware of the 1 in 1,200 risk of getting a fatal cancer that resulted from a CT scan? This is just the fatal cancer. Even this physician wanted the additional CT scan on his infant.

This physician is an example of how medicine really works. Doctors get bullied by patients to treat treat treat. Patients are too often non-compliant with doctor's orders.

I also note a distinct difference in much of the demographics. Notice that the lower-costing health care that the author cites occur in places above the Mason-Dixon line.

While unpopular, there are significant differences in public health that depends on populations. Since I live in Cali, I'll use it as an example.

Latinos represent 33% of California's population. A third of those live below the poverty level, and one in 2 children born in California is latino. Despite being a third of the population, Latinos represent 55% of the uninsured and 40% of Latino children are uninsured. Thus, the uninsured ranks are exploding.

Latinos as a also suffer from preventable diseases like diabetes. 20% over the age of 50 report diabetes - twice the rate of white. Latinas also die more from cervical cancer than other populations because they as less likely to get pap smears.

These are certainly issues that are not faced to the same extent in most other states. These are the things that require some geographic differences. Comparing healthcare issues in different geographic shows radical differences.

My wife is hotter than your wife.

[kbordson 8]

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There was a fascinating article in the New Yorker recently about culture change beeing necessary to save US healthcare. The fascinating part is that the culture needing change is the doctors', not the patients. The article (long but very good) is here: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

My short synopsis: doctors in many areas have created business structures and institutions where they are rewarded by the quantity of care they provide, not the quality. The author contrasts the most expensive region in the country (McAllen, TX) with other similarly sized regions, and finds that the quantity of care (tests, specialists visits, surgeries, etc) being provided in McAllen is much higher than other areas, but the quality of care is no better. He describes the culture of the doctors working in McAllen and other high cost areas as one driven by a strong profit motive instead of a desire to treat and heal patients. To bring down healthcare costs in the US, he suggests we need to find ways to compensate doctors other than by how many tests and labs they order. One suggestion is to pay doctors a salary instead of paying them by the procedure. This method is one of the things that sets the Mayo clinic apart from others. The doctors are free to treat patients as their condition requires without worrying about their personal bottom line.

For what it is worth

I AM salary.

I am typically double booked and even sometimes triple booked. (being an employee, I have little control over that)

I try to avoid unnecessary tests - I get no bonus for labs, no kickback for ultrasounds, no personal benefit at all. I try to avoid unnecessary test .... until patients become threatening. And I don't just mean physically threatening. I mean manipulative. Even tonight, I got a call at 8:30pm. A patients husband didn't make it to her appointment and he was concerned about plans for delivery. So he called at 8:30 at night to "discuss." Since patients have a VERY VESTED interest in his/her/their health, they only want the BEST and they want it guaranteed. But there are no guarantees. (except for the fact that we ALL will die - but they don't want to hear that from their doctor) So they tend to become more demanding .... and would want lil Walker (from the story above) to get a CT and be monitored overnight. Or....




So... explain to me what changes you think that I should make.

[Bolas 5]

Give the patient what they need, not what they want. Try to explain it to them why you are doing what you're doing and make them understand.

If they just don't get it or refuse to tell them to speak to your supervisor. This only works if they have a backbone though.

This is the double edge sword of being an "all powerful" doctor. Rather than having to "fight the system" they just have to fight one person.

Key phrases:
"We have standard procedures we follow. I'm not allowed to deviate."

"I'll be more tha happy to let you discuss it with my manager."

Stupidity if left untreated is self-correcting
If ya can't be good, look good, if that fails, make 'em laugh.

[kbordson 8]

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Give the patient what they need, not what they want. Try to explain it to them why you are doing what you're doing and make them understand.

If they just don't get it or refuse to tell them to speak to your supervisor. This only works if they have a backbone though.

This is the double edge sword of being an "all powerful" doctor. Rather than having to "fight the system" they just have to fight one person.

Key phrases:
"We have standard procedures we follow. I'm not allowed to deviate."

"I'll be more than happy to let you discuss it with my manager."

But you're fighting the "one person" that you're really trying to help. I don't want to FIGHT my patients. I want to be able to help them, educate them, enable them to make informed decisions... while understanding risks.

An analogy would be someone wanting to make a skydive... but lets make it REALLY IMPORTANT skydive... one where if they don't get it, they might (or might not) die. So you try to tell them about the risks of skydiving. RISKS?! If you're a good tandem instructor, your passenger wont die, right? And if something does happen, not only might you loose your rating, but your gear and your house and savings... but you wont be loosing your student loans.

Ya know... I just want to help people.

[justinb138 0]

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This identified a number of problems. First, patients and their parents can often bully a physician into admitting a patient. Costs go up. Is this something cultural that happens more in certain places than others?

I've felt more often than not that I've received more tests than I wanted or needed. In the 8 or so times I've been in the ER for kidney-stone related pain, nearly every doc has wanted to do CTs, etc... despite the fact I was under the care of a urologist who was already doing all of those tests. Unfortunately, when you're in extreme pain and the doc says they won't give you any pain meds until they do the tests, there isn't a compelling reason to argue with them.

[Bolas 5]

Let me first start by saying thank you for caring and helping people.

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But you're fighting the "one person" that you're really trying to help. I don't want to FIGHT my patients. I want to be able to help them, educate them, enable them to make informed decisions... while understanding risks.

How do you think you can ultimately help them more? By using your years and hundreds of thousands of dollars of education and years of experience to determine what may be best for or by doing what they want?

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An analogy would be someone wanting to make a skydive... but lets make it REALLY IMPORTANT skydive... one where if they don't get it, they might (or might not) die. So you try to tell them about the risks of skydiving. RISKS?! If you're a good tandem instructor, your passenger wont die, right? And if something does happen, not only might you loose your rating, but your gear and your house and savings... but you wont be loosing your student loans.

One can die on any skydive, just like one can die at any point. The instuctor anology doesn't really work as they can go with the instructor or not go at all. The risk of one being far greater than the other.

Let's use downsizing as the example. If they think they can downsize safely outside of the standard norms by doing "safe" approaches along with their "mad skillz", they don't understand the risks and should not be allowed to downsize.

If they understand it's a bad idea and WHY it's a bad idea and fully accept that risk: go for it.

Same with your patients. If they fully understand and accept the risk of going against a trained medical professional's treatment decisions, fine. Maybe have them sign a waiver.

If they don't, don't let them. Perhaps refer them to another doctor if they don't like it. This may provide you the most protection if sued for any complications as you can prove you followed standard procedure xyz when the patient presented with versus "why did you do..." and your answer being "the patient told me too."

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Ya know... I just want to help people.

And I and everyone else here thanks you for that compassion but sometimes the best way to help someone is to not just agree with them or tell them what they want to hear.

Stupidity if left untreated is self-correcting
If ya can't be good, look good, if that fails, make 'em laugh.

[lawrocket 3]

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Give the patient what they need, not what they want. Try to explain it to them why you are doing what you're doing and make them understand.

I am shaking my head at this. Figure out how to do this and you'll be a gazillionaire. Further, you will have brought about world peace and a new world of international and domestic tranquility.

"Make someone understand." Yeah. Good fucking luck.
Pass the lotus. I'm hungry.

[Reply]If they just don't get it or refuse to tell them to speak to your supervisor. This only works if they have a backbone though.

This also works if there was no such thing as "ethics" or "informed consent." I'll tell you what. Show up at my office and I'll make you understand the folly of your suggestion. "But lawrocket, you can't make me understand anything I don't wan't to understand."

Incidentally, doctors treat PEOPLE. Don't have a robotics tech be a doctor. And don't turn a doctor into a robotics tech.

This lotus I'm eating aint working.

[Reply]This is the double edge sword of being an "all powerful" doctor. Rather than having to "fight the system" they just have to fight one person.


Yep. And then they fight their employer, the medical board, criminal and civil courts.

One person to fight, indeed. The system here is set up to empower the one person.

[Reply]Key phrases:
"We have standard procedures we follow. I'm not allowed to deviate."


You have just described nursing.

I don't want a nurse operating on me. I want a doctor.


[Reply]"I'll be more tha happy to let you discuss it with my manager."

You've just described nursing. "I'll ask the doctor." A nurse is a bureaucrat who operates under standardized procedures. Something happens outside of it? They ask a doctor.

The doctor is the captain. The doctor is the manager. The doctor is the artist whose art conforms to a standard of care.

Ultimately, who makes medical decisions?

PATIENTS. I decide what the doctor does and do not do. Not you. Not a Nobel Prize winner. Me.

Doctors give me options amd explain the risks and benefits.

Sure, eliminating doctors in favor of nurses will save trillions. What wonderful care.

"What? This lotus is a placebo?"

My wife is hotter than your wife.

[lawrocket 3]

He can't make you understand, doctor.

Ergo, he has no backbone. According to his definition.

My wife is hotter than your wife.

[Bolas 5]

First off...



I love your writing style.

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Give the patient what they need, not what they want. Try to explain it to them why you are doing what you're doing and make them understand.

I am shaking my head at this. Figure out how to do this and you'll be a gazillionaire. Further, you will have brought about world peace and a new world of international and domestic tranquility.

It's all in knowing what you know and what you don't know.

Ask me a general skydiving question and I can probably answer it.

Ask me a computer question and I can probably give you my professional opinion.

Ask me a car repair question and most likely get a puzzled look.

It doesn't mean that with eventually with enough trial and error, and google research I couldn't repair a car, but it's really not very efficient for me to do so (unless it's just an enjoyable hobby) nor should I give advice to others.

I'd refer them to a mechanic and I'd use one as well.

When I go to the dentist or doctor, I get the options and then ask "what do you recommend?"

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"Make someone understand." Yeah. Good fucking luck.
Pass the lotus. I'm hungry.

Get your own. This lotus is mine.

If they don't understand how are they able to truly understand the consequences of their actions or inactions?

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[Reply]If they just don't get it or refuse to tell them to speak to your supervisor. This only works if they have a backbone though.

This also works if there was no such thing as "ethics" or "informed consent." I'll tell you what. Show up at my office and I'll make you understand the folly of your suggestion. "But lawrocket, you can't make me understand anything I don't wan't to understand."


Which is less ethical? Letting someone who doesn't understand the risk of their action or inactions make bad decisions or doing everything in your power to stop them?

You even have to admit, your profession has done more to seemingly purposely complicate and confuse things.

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Incidentally, doctors treat PEOPLE. Don't have a robotics tech be a doctor. And don't turn a doctor into a robotics tech.

This lotus I'm eating aint working.

There are certain benefits from having standard repeatable processes.

You gotta let it sit on your tongue for a bit.

[Reply]

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This is the double edge sword of being an "all powerful" doctor. Rather than having to "fight the system" they just have to fight one person.

Yep. And then they fight their employer, the medical board, criminal and civil courts.

One person to fight, indeed. The system here is set up to empower the one person.


[Reply]

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Key phrases:
"We have standard procedures we follow. I'm not allowed to deviate."

You have just described nursing.

I don't want a nurse operating on me. I want a doctor.


I want someone that is going to follow standard medical procedures and only deviate where they feel a need to.

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[Reply]"I'll be more tha happy to let you discuss it with my manager."

You've just described nursing. "I'll ask the doctor." A nurse is a bureaucrat who operates under standardized procedures. Something happens outside of it? They ask a doctor.

The doctor is the captain. The doctor is the manager. The doctor is the artist whose art conforms to a standard of care.

Ultimately, who makes medical decisions?

PATIENTS. I decide what the doctor does and do not do. Not you. Not a Nobel Prize winner. Me.

Doctors give me options amd explain the risks and benefits.

Sure, eliminating doctors in favor of nurses will save trillions. What wonderful care.

"What? This lotus is a placebo?"

Oh dude, that was hemlock. Boy is my face red.

Doctors are more like focused project managers than captains. They have their responsibilities but still answer to those above them.

No one is talking about eliminating doctors just giving them more authority by making it seem like they have less.

Karen talks of being threatened into giving what she knows is the wrong thing or things people don't need. That is simply disrespectful and should not be tolerated. More important "bullying" should not be allowed to work.

What a difference a generation or two makes. My grandparents could be told by a doctor to stand on their head an hour a day and they'd do it.

My parents would question that doctor and maybe get a second opinion.

Seems mine and younger just say "Fuck you and give me some drugs."

Stupidity if left untreated is self-correcting
If ya can't be good, look good, if that fails, make 'em laugh.

[Bolas 5]

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He can't make you understand, doctor.

Ergo, he has no backbone. According to his definition.

Two in a row.

I think we do want the same thing, what's best for her patients, we just seem have two different methods of accomplishing that goal.

Stupidity if left untreated is self-correcting
If ya can't be good, look good, if that fails, make 'em laugh.

[lawrocket 3]

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First off...

I love your writing style.

We're both assholes. If ever in Fresno, I'll certainly buy you several beers, hand you a dress and break out the video camera.

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When I go to the dentist or doctor, I get the options and then ask "what do you recommend?"

Of course. Then again, I am often asked (in fact just yesterday) "What is the best way to go about this?" And I always say, "I will never answer the question of what is 'best.' Because what is best for me is not best for you. I can give predictions and estimates. If they say, "We have to do this as economically as possible" it means that we won't be taking depositions. And I can say, "The depositions would provide very useful information buit they will cost" and leave it to the client.

This is as it should be - and the choice left up to the client/patient as to how to proceed.

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Get your own. This lotus is mine.

Bogart!

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If they don't understand how are they able to truly understand the consequences of their actions or inactions?

The understanding works both ways. There are times when I think a client does a foolish thing. There are times when I tell a client, "It is in my own best interest to continue this litigation because it can mean that my kids go to college. On the other hand, the probability is that trial will not result in a better result for you, though there is a chance we can pull out a better result.

"But the option is yours. If it is worth the risk, then we will proceed."

It's sound practice. They have been fully advised and have made their choices. Doctors, like lawyers, are fiduciaries.

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Which is less ethical? Letting someone who doesn't understand the risk of their action or inactions make bad decisions or doing everything in your power to stop them?

Most people DO understand the risks. Think of skydiving - the majority of the population does not find it to be an appropriate risk - there is simply no way that it is worth the risk to them. There are plenty of people - educated and intelligent - who find those who skydive to be insane. I readily admit that the sport is irrational.

But if the choice is made for you that you clearly must not fully appreciate the risks (anyone who did would not do it) and therefore you will not, then the decision is made.

It's YOUR decision. In fact - experienced jumpers I know take the same steps to inform newbies that this is a risky sport. We allow people to make foolish moves. As billvon himself states about a low-timer on a small canopy, "I hope he breaks his femur." It's not meant to be uncaring because he knows that something will happen and a broken femur is as good of a bad outcome as possible, and will be a learning event.

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There are certain benefits from having standard repeatable processes.

Absolutely. And the vast majority of surgeries are performed the same way. Doctor A doing a laparoscopic cholecystectomy is going to follow the same general procedures as Doctor B. This is where "standard of care" fits in. Doctors must meet that standard.

Nevertheless, doctors go through decision trees - like you do in your work. There are procedures. But each branch of a decision tree can require the independent medical judgment. Once that person is out, the surgeon may find the peritoneal adhesions that prevent clear visualization. The surgeon must determine through independent judgment whether to abort the lap and go with an open surgery or proceed with the lap. "Which is more risky?"

These are judgment calls that standard procedures cannot manage. If the standard procedure is, "Upon observation of adhesions, abort the lap and proceed with open" could be a procedure, which could greatly increase the risk of additional complication, infection, blood loss, etc.

Which is more or less risky? I think it should be left to surgical judgment.

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You even have to admit, your profession has done more to seemingly purposely complicate and confuse things.

I don't have to admit anything.

But I readily admit that my profession has screwed up plenty of things. Sure, it's made medicine "safer" but I am convinced lawyers have made medicine extremely expensive. If the cost of medicine is to go down, tort reform is issue No. 1 to tackle.

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There are certain benefits from having standard repeatable processes.

Absolutely. Like emergency procedures. Absolutely.

Nevertheless, there are times when the emergency procedures may need modification based upon the nature of the mal. AAD's follow standard procedures. There is no situational judgment other than rate of descent at a certain point. This is a good thing most of the time. It has also killed people through working exactly as intended.

A standard procedure that would kill 1% of patients would not last long.

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I want someone that is going to follow standard medical procedures and only deviate where they feel a need to.

Bingo! You have just described what doctors do every day. A "standard procedure" is not subject to deviation. It also means that if a doctor knows the standard procedure will lead to an adverse result and thinks that a deviation from it has a better chance of success, a doctor will not deviate because deviation from a "standard procedure" is, to lawyers like me, prima facie negligence if it doesn't work.

"Standard procedure" by its nature implies no discretionary function. The "standard of care" recognizes that there is more than one way to do something and that another similarly situated doctor would find the choice to be reasonable.

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No one is talking about eliminating doctors just giving them more authority by making it seem like they have less.

It gives more of one type of authority but less of another. Telling a doctor that he or she must do something in a certain way each time is not providing with authority. It's turning a doctor into a nurse - nurses do not have discretion.

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Karen talks of being threatened into giving what she knows is the wrong thing or things people don't need. That is simply disrespectful and should not be tolerated. More important "bullying" should not be allowed to work.

Correct. And she also has inherently recognized the superiority of the patient in making decisions. In some ways, giving the doctor more authority is a good thing. However, putting personal decisions in the hands of another is otherwise known as "Nanny State."

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My parents would question that doctor and maybe get a second opinion

Standardized procedures would mean that there is no such thing.

Great discussion.

My wife is hotter than your wife.

[Bolas 5]

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First off...

I love your writing style.

We're both assholes. If ever in Fresno, I'll certainly buy you several beers, hand you a dress and break out the video camera.

You think yours would fit me?

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A standard procedure that would kill 1% of patients would not last long.

Ah yes, the "if it saves only one child..." argument.

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Correct. And she also has inherently recognized the superiority of the patient in making decisions. In some ways, giving the doctor more authority is a good thing. However, putting personal decisions in the hands of another is otherwise known as "Nanny State."

Unfortunately since personal responsibility and accountability seems to be dead, it's sadly the next step. When people are suing and winning over stupid decisions they made...

The only way to reverse the trend is to actually hold people accountable for their actions again. This "having cake and eating it too" is a path to nowhere.

Stupidity if left untreated is self-correcting
If ya can't be good, look good, if that fails, make 'em laugh.

[billvon 3,009]

>The only way to reverse the trend is to actually hold people accountable
>for their actions again.

This works for everything but health care. No one, from you and I to ER physicians to EMT's, will let someone die because they can't pay. From that basic decision comes a lot of problems, which is what this discussion is about.

[Bolas 5]

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>The only way to reverse the trend is to actually hold people accountable
>for their actions again.

This works for everything but health care. No one, from you and I to ER physicians to EMT's, will let someone die because they can't pay. From that basic decision comes a lot of problems, which is what this discussion is about.

I'm not talking $$$ right now. I'm talking going against medical advice and then suing and winning later.

On the $$$ side, how do you propose providing health care in such away that those that can't afford it still get it but treat it is a privilege, not an entitlement and therefore don't or can't do things like use hospitals and ER's for standard or basic preventative care?

Stupidity if left untreated is self-correcting
If ya can't be good, look good, if that fails, make 'em laugh.