On the Passing of American Medicine
Moss David Posner M.D.
September 12, 2005
For four decades now, I have watched my profession slowly bleed to death. I saw it coming in 1965 when "Medicare" was legislated into being.This creation was to provide all seniors healthcare. Tragically, it has done no such thing; but it has done worse.
No sooner than the ink was dry on the legislation, the policies of Medical Boards became hostile, accusative, and menacing to the physicians. As the law became--predictably--more costly, with no end in sight, physicians could no longer support their private practices and either retired, congealed into groups, or joined HMO's, the majority of which entities are more concerned with costs than care, and generally are started by very cynical, mercenary and mediocre physicians. (I've known many of them.)
The general purpose of the regulatory agencies, as with most bureaucratic organizations, is, first, to justify its own existence one way or another, and second, to destroy the physician and the private practice of medicine. The Powers That Be realize only too well the basic autonomy, the authority and the earning power of the Medical Profession; and these sources have systematically and inexorably attempted to control or otherwise destroy this profession.
This is the reason for advertisements which tout a specific prescription medication, and suggest that the viewer "ask...(his or her)...doctor" about the medication in question. The attempts on the part of the Pharmaceutical Industry to influence physicians is legend. Now, not content with this, they have taken off the gloves and are going for the patients directly, with full knowledge and complete indifference to the doctors, as if to say, "We don't need you any more."
This is also the reason for all of the "algorithms" and other "outcome-based" idiocy: to standardize and reduce to a set of rote, mindless actions, those procedures, and most of all--judgments, which constitute the Practice of Medicine.
Take, for example, the original algorithms, those ones involved in the procedures of CPR, (cardiopulmonary resuscitation.) Can you imagine the effect of having people who have never had the lives of others as their responsibility, following the cookbook flow diagram (algorithm,) which tells them what potential lethal medications to give to people in critical condition--and in what sequence? How many people were killed, receiving an ampoule of sodium bicarbonate every ten minutes during a code, as called for by the original algorithm? They were changed when somone realized they were killing the patients.
How many times during CPR did people receive the wrong medication, including atropine, when distinctions were made between EMD, asystole and Ventricular fibrillation--all potentially serious states, all treated differently in the original algorhythms, when with all of these pulsless patients, an amp of epinephrine would have been safe to use, in many cases, as first-line medication? I thank God that I never followed algorithms, but rather, used my own judgment. Oh, and by the way, there a growing body of evidence which questions the efficacy of CPR in toto.
Far fetched? Think again. How would you like your surgeon to operate on you by following an algorithm? Or possibly your airlines pilot? Better yet, let's start closer to home: How about an algorithm for sex, including foreplay? Or do all of these activities require clinical judgment?
And it is precisely that--clinical judgment--that is being replaced. That is the excuse for "outcome-based education," or training. If you doubt this, ask yourself one simple question: Why aren't such algorithms limited only to use by those who are not expected to be possessed of sufficient training and experience to decide what to do in such situations? Why must doctors be made to follow them as well? Do these people seriously believe that adequately trained physicians cannot use their clinical judgment in crisis situations, as they do in all others? Did these people seriously believe that doctors were floundering, bereft of any ability to treat in emergencies, until "they," the destroyers arrived on the scene?
In other words, these sources are trying to destroy the physicians and substitute know-nothings instead--those who are wiilling to be molded, who can be taught what and how to think, and who will cost infinitely less than would physicians. This is the source of the "para-people," the hamburger-helpers, such as Physician Assistants, and Nurse Practitioners. In this regard, it's interesting to note that the Nurse Practitioners, having had in their own roles as nurses, relationships with doctors, appear to have some semblance of respect for their limitations, unlike most Physician Assistants, many of whom (not all) who are totally convinced they know "it" all, and have nothing but contempt and disrespect for the doctors, who, these people dimly suspect, really know something more basic than they, the PA's know.)
The best that can be said for Physician Assistants is that they are first-rate, third-rate physicians. This is neither compliment nor insult; any potential physician who was trained as a Physician’s Assistant could not help but turn out to be the same.
If the above appears too harsh, dear reader, ask yourself one question: If your life or that of a loved-one was on the line, would you prefer a physician or one of the “assistant” class of practitioners? While we’re on the subject, if your life were on the line, would you prefer a seasoned criminal attorney or a seasoned paralegal?
One of the fringe benefits of these controls on medicine is to drive up the cost of medical care and services, with no end in sight. It is a vicious cycle, the mechanism of which no one dare name. By attempting to freeze in time, the cost of various services, (hereinafter known as "indices,") and the indications for such services, they, the third parties, the middlemen, inevitably and indiscriminately, force, simultaneously, both parties to blind abuse: The doctors, to order indiscriminately, and the patients, to consume indiscriminately.
This is necessitated for two reasons: First, in such a situation, there is no way to measure the true need or the true cost of any goods or services. This is because in any economic system the cost is the equilibrium point between supply and demand. But in this new scenario, there is no objective standard for either--supply or demand.,
Second, and as a a consequence, like musical chairs, all parties must push and shove: The doctors do indiscriminate procedures because of the inherent limitation on payments to them, the patients indiscriminately demand services, because of the inherent limitation on availability, and the middle man withholds as much of both payments and services as he can, because of the inherent limited availability of both money and services, as well as the political backlash and threat to his job as well.
In such situations, it would be true to say, to the doctor, "What we pay you is what this is worth," and to the patient, "what we allow is what you really need." In such a system, this would be the very definition of “payment” and of “need.” How could it be otherwise?
Of course the doctor cannot survive--do good work and get paid for same--in such a situation. So he either quits, or compromises the quality of his work or the cost of good equipment. He can increase the number and nature of the things for which he bills. And the patient cannot survive on what is being offered, so he increases the amount and the frequency of his demand for goods and services. He can go the the emergency room for trifles and can call 911 on the slightest provocation.
The result of all this is a further diminution of supply by the middle man to both doctor and patient, and so we see the vicious cycle. This is why doctors increase volume and decrease quality of services or go out of practice, why pharmacies order the cheapest products, or falsely bill Medicare or Medical, and why patients develop a pragmatically necessary hypochondriasis and burden the system with incessant demands. This is why patients end up injured or dead, and why doctors and pharmacists end up broke or in jail.
When I was in private practice, I worked harder and had longer hours, was more available, more involved in my patients’ care, had more to say about my patient’s care, had more challanges, and got paid less per unit of time worked. My wife and kids were wonderful and did the best they could with the time I could give them. I was tired and happy.
Now I work hard, and I have shorter hours. I am less available, less involved with my patients’ care, have less to say about my patients’ care, which frustrates and worries me, have fewer challanges, and get paid more per unti of time worked. My kids have no problem as I am home every night at the same time. I am not tired and not satisfied. The life is gone out of my practice, and it is oozing out of me as well.
It is about power and money. It's about control. Like a coal mine, the Destroyers use and abuse things, chew them up and spit them out; and when there is no more to use, they walk away and start grazing, looking for something else to control, to destroy.
That is why you see political candidates for public office talk of "delivering" Health Care--as if it were in the nature of a guided missile, having no intimate or reciprocal relationship between the initiator and the receiver, and by its existence, separating the two. They all speak of "delivering" health care, like Parcel Post, as if it were theirs to control, as if it were independent of the two essential parties to the relationship--the doctor and the patient. In the eyes of these people, the latter two are expendable.
So doctor, what's the answer?
The answer is to return to the private practice of medicine. This includes eliminating one or two thousand local, state, and federal agencies. They will never be missed. The first step, however, is the education of the American people into the economic and associated moral dynamics of medical care--or of any other marketable goods and services.
The second step is to provide incentives, perhaps tax breaks, to those who wish to start their own practices--some doing so for the first time. (Don't hold your breath, folks. Bureaucrats would rather give up The Ghost than to give up control.)
How many of you can remember when your doctor was--your doctor, literally. He remains in practice in an office he rents or pays for, and survives because he is good at what he does and for no other reason. He makes house calls and you can actually get him on the telephone. Or perhaps you'd prefer your generic doctor, who happens working on the day or night you get sick, who will be off call in a few hours, who works in a cubby hole, and has never struggled to get his own practice together in his life? Are my ideas just pie in the sky?
No so. In Oregon and other states many of the people do not like HMO's and the like. Private practitioners are in demand--and they are tired but happy.
Gosh! I wish I could be tired and happy like that. I'd take it in a heartbeat.
No sooner than the ink was dry on the legislation, the policies of Medical Boards became hostile, accusative, and menacing to the physicians. As the law became--predictably--more costly, with no end in sight, physicians could no longer support their private practices and either retired, congealed into groups, or joined HMO's, the majority of which entities are more concerned with costs than care, and generally are started by very cynical, mercenary and mediocre physicians. (I've known many of them.)
The general purpose of the regulatory agencies, as with most bureaucratic organizations, is, first, to justify its own existence one way or another, and second, to destroy the physician and the private practice of medicine. The Powers That Be realize only too well the basic autonomy, the authority and the earning power of the Medical Profession; and these sources have systematically and inexorably attempted to control or otherwise destroy this profession.
This is the reason for advertisements which tout a specific prescription medication, and suggest that the viewer "ask...(his or her)...doctor" about the medication in question. The attempts on the part of the Pharmaceutical Industry to influence physicians is legend. Now, not content with this, they have taken off the gloves and are going for the patients directly, with full knowledge and complete indifference to the doctors, as if to say, "We don't need you any more."
This is also the reason for all of the "algorithms" and other "outcome-based" idiocy: to standardize and reduce to a set of rote, mindless actions, those procedures, and most of all--judgments, which constitute the Practice of Medicine.
Take, for example, the original algorithms, those ones involved in the procedures of CPR, (cardiopulmonary resuscitation.) Can you imagine the effect of having people who have never had the lives of others as their responsibility, following the cookbook flow diagram (algorithm,) which tells them what potential lethal medications to give to people in critical condition--and in what sequence? How many people were killed, receiving an ampoule of sodium bicarbonate every ten minutes during a code, as called for by the original algorithm? They were changed when somone realized they were killing the patients.
How many times during CPR did people receive the wrong medication, including atropine, when distinctions were made between EMD, asystole and Ventricular fibrillation--all potentially serious states, all treated differently in the original algorhythms, when with all of these pulsless patients, an amp of epinephrine would have been safe to use, in many cases, as first-line medication? I thank God that I never followed algorithms, but rather, used my own judgment. Oh, and by the way, there a growing body of evidence which questions the efficacy of CPR in toto.
Far fetched? Think again. How would you like your surgeon to operate on you by following an algorithm? Or possibly your airlines pilot? Better yet, let's start closer to home: How about an algorithm for sex, including foreplay? Or do all of these activities require clinical judgment?
And it is precisely that--clinical judgment--that is being replaced. That is the excuse for "outcome-based education," or training. If you doubt this, ask yourself one simple question: Why aren't such algorithms limited only to use by those who are not expected to be possessed of sufficient training and experience to decide what to do in such situations? Why must doctors be made to follow them as well? Do these people seriously believe that adequately trained physicians cannot use their clinical judgment in crisis situations, as they do in all others? Did these people seriously believe that doctors were floundering, bereft of any ability to treat in emergencies, until "they," the destroyers arrived on the scene?
In other words, these sources are trying to destroy the physicians and substitute know-nothings instead--those who are wiilling to be molded, who can be taught what and how to think, and who will cost infinitely less than would physicians. This is the source of the "para-people," the hamburger-helpers, such as Physician Assistants, and Nurse Practitioners. In this regard, it's interesting to note that the Nurse Practitioners, having had in their own roles as nurses, relationships with doctors, appear to have some semblance of respect for their limitations, unlike most Physician Assistants, many of whom (not all) who are totally convinced they know "it" all, and have nothing but contempt and disrespect for the doctors, who, these people dimly suspect, really know something more basic than they, the PA's know.)
The best that can be said for Physician Assistants is that they are first-rate, third-rate physicians. This is neither compliment nor insult; any potential physician who was trained as a Physician’s Assistant could not help but turn out to be the same.
If the above appears too harsh, dear reader, ask yourself one question: If your life or that of a loved-one was on the line, would you prefer a physician or one of the “assistant” class of practitioners? While we’re on the subject, if your life were on the line, would you prefer a seasoned criminal attorney or a seasoned paralegal?
One of the fringe benefits of these controls on medicine is to drive up the cost of medical care and services, with no end in sight. It is a vicious cycle, the mechanism of which no one dare name. By attempting to freeze in time, the cost of various services, (hereinafter known as "indices,") and the indications for such services, they, the third parties, the middlemen, inevitably and indiscriminately, force, simultaneously, both parties to blind abuse: The doctors, to order indiscriminately, and the patients, to consume indiscriminately.
This is necessitated for two reasons: First, in such a situation, there is no way to measure the true need or the true cost of any goods or services. This is because in any economic system the cost is the equilibrium point between supply and demand. But in this new scenario, there is no objective standard for either--supply or demand.,
Second, and as a a consequence, like musical chairs, all parties must push and shove: The doctors do indiscriminate procedures because of the inherent limitation on payments to them, the patients indiscriminately demand services, because of the inherent limitation on availability, and the middle man withholds as much of both payments and services as he can, because of the inherent limited availability of both money and services, as well as the political backlash and threat to his job as well.
In such situations, it would be true to say, to the doctor, "What we pay you is what this is worth," and to the patient, "what we allow is what you really need." In such a system, this would be the very definition of “payment” and of “need.” How could it be otherwise?
Of course the doctor cannot survive--do good work and get paid for same--in such a situation. So he either quits, or compromises the quality of his work or the cost of good equipment. He can increase the number and nature of the things for which he bills. And the patient cannot survive on what is being offered, so he increases the amount and the frequency of his demand for goods and services. He can go the the emergency room for trifles and can call 911 on the slightest provocation.
The result of all this is a further diminution of supply by the middle man to both doctor and patient, and so we see the vicious cycle. This is why doctors increase volume and decrease quality of services or go out of practice, why pharmacies order the cheapest products, or falsely bill Medicare or Medical, and why patients develop a pragmatically necessary hypochondriasis and burden the system with incessant demands. This is why patients end up injured or dead, and why doctors and pharmacists end up broke or in jail.
When I was in private practice, I worked harder and had longer hours, was more available, more involved in my patients’ care, had more to say about my patient’s care, had more challanges, and got paid less per unit of time worked. My wife and kids were wonderful and did the best they could with the time I could give them. I was tired and happy.
Now I work hard, and I have shorter hours. I am less available, less involved with my patients’ care, have less to say about my patients’ care, which frustrates and worries me, have fewer challanges, and get paid more per unti of time worked. My kids have no problem as I am home every night at the same time. I am not tired and not satisfied. The life is gone out of my practice, and it is oozing out of me as well.
It is about power and money. It's about control. Like a coal mine, the Destroyers use and abuse things, chew them up and spit them out; and when there is no more to use, they walk away and start grazing, looking for something else to control, to destroy.
That is why you see political candidates for public office talk of "delivering" Health Care--as if it were in the nature of a guided missile, having no intimate or reciprocal relationship between the initiator and the receiver, and by its existence, separating the two. They all speak of "delivering" health care, like Parcel Post, as if it were theirs to control, as if it were independent of the two essential parties to the relationship--the doctor and the patient. In the eyes of these people, the latter two are expendable.
So doctor, what's the answer?
The answer is to return to the private practice of medicine. This includes eliminating one or two thousand local, state, and federal agencies. They will never be missed. The first step, however, is the education of the American people into the economic and associated moral dynamics of medical care--or of any other marketable goods and services.
The second step is to provide incentives, perhaps tax breaks, to those who wish to start their own practices--some doing so for the first time. (Don't hold your breath, folks. Bureaucrats would rather give up The Ghost than to give up control.)
How many of you can remember when your doctor was--your doctor, literally. He remains in practice in an office he rents or pays for, and survives because he is good at what he does and for no other reason. He makes house calls and you can actually get him on the telephone. Or perhaps you'd prefer your generic doctor, who happens working on the day or night you get sick, who will be off call in a few hours, who works in a cubby hole, and has never struggled to get his own practice together in his life? Are my ideas just pie in the sky?
No so. In Oregon and other states many of the people do not like HMO's and the like. Private practitioners are in demand--and they are tired but happy.
Gosh! I wish I could be tired and happy like that. I'd take it in a heartbeat.
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