Anonymous

Vance Harris MD writes:

We are our own worst enemies, as we have allowed insurance companies and Medicare to set the value of our services. Clearly those values they impose have nothing to do with our contribution to the health of our patients or the cost savings we bring about.

Case in point:

How many dozens of chest pain patients have I seen in the last month who I didn’t order an EKG, get a consult, set up nuclear imaging or send for a cath? Only I have the advantage of knowing just how anxious most of these patients are and that they have had the same symptoms time and again over the last 20 years. After a pointed history and exam, I am more than willing to make the call that 27 hours of chest pain is most likely not angina in nature. When I take the responsibility on my shoulders I am saving the system tens of thousands of dollars. Most of these patients present to my office directly and are worked into a busy day pushing me even deeper into that mire of tardiness for which I will be chastised by at least 6 patients before the end of the day. Most of those who scold me are retired and have more free time in a day than I get in a month. My reward for working these people in and making a call that puts me at some risk is at most $75 if I count the less than $25 I get paid for being able to read an EKG without sending it off to be interpreted by a cardiologist. My incentive pay for saving thousands of dollars on each patient for 1-2 days in the hospital, stress treadmill and cardiologist referral is $75. Now there is motivation on a busy day to not send someone to the ER.

How many times has an anxious patient come in, almost demanding an endoscopy, who I examined, after taking a good history, and then decided to treat for 3-4 weeks before making the referral? Few of these patients are happy with me after the visit, no matter how many times I explain that it is reasonable to treat their reflux symptoms for several weeks before considering endoscopy. This delay in referral has lead to many a tense moment in the last 20 years. Cost savings to the system is again thousands of dollars each and every time I do this. I am willing to make the call and go with the treatment first before getting the scope. My reward is about $55 from Medicare and the Big Blues.

How many low back pain patients have come to the office in agony knowing that there has to be something serious to cause this kind of pain? Again a good history and a directed exam allows me to reassure the patient that there is nothing we need to operate on and that the risk of missing anything in this setting is low. This takes a lot of time to explain as I teach them why they don’t need, and better yet, why they don’t want to get an MRI at this point. If someone else ordered the MRI guess who gets to explain the significance of bulging disks and narrowed foramen to an alarmed patient? Setting realistic expectations on recovery and avoiding needless imaging that rarely helps, in the acute setting of a normal exam, saves the system thousands of dollars again. My reward is another $55 if I am lucky.

How many times does a good shoulder exam allow me not to order an MRI giving the patient time to heal and recover before imaging racks up another couple of thousand dollars followed by orthopedic referral for a shoulder that doesn’t need surgery? Another $55 will shower down on me at the end of the day when I send off the bill for that exam.

How many basal cell and squamous cell cancers have I discovered while examining some ones shoulder or abdomen or even a sore throat? How many of those was I stupid enough to remove the same day, only to find out that I would be paid for only one procedure and it would always be the least expensive of the two? How many appeals have been successful to Medicare when I performed the service and was denied payment?

How many diabetics do I struggle with, trying to get them to take better care of themselves? How many hours have I spent with teenage diabetics who will not check their blood sugars and forget half of their insulin doses? I have spent hundreds of hours dealing with them and their families trying to effect changes that will someday allow them to get their disease under control. I do this because the only Endocrinologist in the county will not see pediatric diabetics. I can’t say that I blame him as the time spent seems like a total waste. That is, until one day they open their eyes and want to take care of themselves. My reward for years of struggle and years of 30 minute visits trying to get them to take responsibility for their health is a few hundred dollars at best. The savings to society for my hard work and never give up attitude is in the tens of thousands of dollars.

I continue on in my 22nd year giving advice and services to 30 plus patients each and every day. Having me in the system has resulted in savings in the hundreds of thousands of dollars each and every year. My financial incentive to hang in there and work hard is the following. Twenty years ago I made about twice as much as I do now. This year I will make less as it seems even more of the claims are being reviewed while payment sits in someone else’s account drawing interest.

I have always served my fellowman out of a sense of love and compassion and for those reasons I went into medicine. I have been richly rewarded by my patients over the decades as they appreciate my judgment and skills. Isn’t it a shame that after all this time and with skills honed by decades of experience, I can barely afford to work as a physician? Taxes will be collected, no pass for the working physician, not like the Goldman Sacks guys and their buddies with the 9 billion in bonuses given last year after the 58 billion in funds we gave them.

My parting words next year will be good luck having PA’s provide the safety net with their 2 years of training. Good luck getting newly trained physicians to take over once they see my salary. Good luck having internists in your community with only 1% of medical students going into Internal Medicine. Good luck recruiting the primary care specialists when you are short 70,000 now and 1/3 plan on retirement within 3 years.

If there is any irony in this at all, it is that I will find myself in the same boat as I struggle to find a doctor to take care of me. Now that is ironic. Anyone know who is taking new patients in California?

Vance Harris, MD

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34 Responses for “Commentology: Thoughts on the Death of Primary Care”

  1. Thomas Schwieterman MD says:

    Vance,
    Thanks for posting this. As a fourth generation family doc in rural Ohio, your message rings loud and true for me. Despite 115 years of successful healthcare delivery without lawsuits and a over-full patient population, we are now finding it very hard to make ends meet.
    Your message is similar to the lead story in today’s USA Today. I fear that most people in the industry and in government are underestimating the consequences of a vastly underserved primary care foundation to handle our current and future healthcare burdens.
    Death in our complicated patients often occurs not from one disease, but from a progressive series failures in multiple organ systems. The death of primary care is analogous with coincident failures in providing proper prestige, adequate salary, and rewards for the efforts you mentioned above. All three will need to be addressed before we can expect primary care to flourish.

  2. Dr. Pandey says:

    Dr. Harris
    I am one of the biggest fan of PCPs. I also believe that they can be used to cut cost and improve care if given right tools, right incentives, and protection.
    I do know they are relatively underpaid but I am not sure I agree with your dedcription of poverty. I think we shall reduce the salaries of specialists as it is too high. And NO, I do not agree with CEOs salary also specially if they are unable to create a business model where there are no lay offs. Person with even a high school education can do their job….they have no money, they fire people and when they do have, they hire.
    There is no brain involved…
    I hope that the health reform, which seems to be already on wrong path, will give PCPs power to be health manager….and help cut cost.
    rgds
    ravi
    blogs.biproinc.com/healthcare
    http://www.biproinc.com

  3. pcb says:

    a priceless post. absolutely hit it out of the park.
    ftw, as the young people say.
    (for the win)

  4. bev M.D. says:

    A very powerful post, and most in the profession (even if not in primary care) can vouch for its accuracy. Thanks for helping illuminate the situation.

  5. MD as HELL says:

    The death of primary care can be attributed to the following:
    1. No standing in court.
    2. Failure to diagnose…
    3. Standards of care being decided by juried of lay people who of course think the standard of care would have to be assuring the plaitiff had not died or suffered serious injury. Anything short of this is considered “neglegent”.
    Hence the rise of specialists and the consumer movement usurping medical control of the dying patient and the management of the death of a patient from the patient’s doctor to the family who, quite naturally, do not want guilt heaped on them by the death of a loved one.
    Hence the rise of PEG tubes and dialysis for all, mega workups ON DEMAND in the ED to show a patient is stable enough to go home.
    Hence the rise of statin therapy for all.
    Welcome the age of the specialist. The government initially neutered primary docs who were the cost drivers in the 1980′s. Now primary care is irrelevant to anything.
    Primary docs used to deliver babies until the tort crisis made it economically untenable with huge premiums required to cover the unexpected outcomes that led to expensive care of surviving babies. Todays obstetrician is being crushed by the same forces. More and more OB-GYN docs are dropping obstetrics.
    The missing ingredient in the futue of primary care is a relationship. Docs used to practice in a single community forever. It was rare one ever moved. Now primary docs move frequently to find a better life style, more money or less litigation.
    I trained in family practice. The very next day I started working in an ED. I have been there ever since (same one, also rare.) I have watched my community’s medical staff deteriorate. The family docs no longer admit there own patients, because it is not economically feasable to do so. This is true for our general internists as well.
    We now are having a huge pay for call discussion with our surgeons. This is a nationwide trend where the hospital has to pay the surgeon just to be available. We canot recruit new docs here if the lifestyle includes every third night call. Unassigned coverage for the ED is getting very shaky.
    The only way out is for the patient to once again value a long term relationship with a doctor who will help them live well and long and then help them die without pain and without family guilt and without liability for being a good doc.

  6. rbar says:

    Most of the described problems don’t have much to do with the problem of specialist vs. primary care, but rather with a culture of immediate satisfaction and desire for health care technology/gadgets that IMHO is particularly strong in the US.
    I am a nonsurgical specialist. For many problems, watchful waiting is very reasonable, and it is actually my specialty training and experience that make me comfortable suggesting that (as opposed to a PCP who may not feel comfortable with observation). The problem is: very many, if not most patients want tests (pictures, labs) +/- “specific” therapy (prescription drugs) and think that they miss out on something.
    And the other side is the threat of litigation, as MD as HELL already explained.
    It can’t be said often enough: for physicians, there is barely a reason NOT to order any (noninvasive) test, but multiple motivations to order many, even worthless ones.

  7. jd says:

    What a fantastic argument for no longer paying physicians on a fee for service basis.

  8. MD as HELL says:

    No fee no service.

  9. dwhite says:

    WOW! How eloquent. You have written exactly what I was feeling a year ago when I left general internal medicine for hospital medicine. Primary care is a sinking ship with CMS and malpractice lawyers making direct hits broadside.

  10. Claudia B Rutherford PhD says:

    You make such good points and I empathize with your plight! I am a clinical psychologist and I couldn’t help but notice as I read your post that many of the people you mentioned who came in with physical symptoms, you seemed to suspect were actually having anxiety or depression. Our whole healthcare system discourages prevention and it also discourages mental health treatment. Just as primary care doctors are grossly underpaid, so are psychologists and social workers. The current system discourages us from working collaboratively with other providers (for example, calling the primary care doctor to talk about what contribution mental health issues may have or may not have in a particular patient’s symptoms). It discourages us from trying to solve anything without immediately suggesting psychiatric medication, which certainly has its place in some situations but not all and is not a panacea. It is so frustrating how far the existing healthcare system is from actual provision of care to patients and our ability to manage financially as providers.

  11. Economics 101 says:

    I am a family physician. My twenty-something daughter graduated from an ivy league school with a BS in computer science. She now works for a well-known tech company. Salary + bonus + stock options = more than $200K/yr and great benefits to boot. Her future is bright with boundless upward mobility. Cohorts who are going to medical school? 4 years undergrad + 4 years med school + 4 years residency + lost opportunity in the workplace = a whole lot less than $200K if they go into primary care and not a lot of upward mobility. Why don’t we have enough primary care physicians? Young people are better at math than we think.

  12. DrWonderful says:

    There will be no health insurance reform until the health insurance industry is no longer allowed to collude and price fix. Repeal their anti-trust exemption and see how quickly they behave.

  13. Jim Bertsch says:

    Primary care physicians are victims of the current health care system. Especially those who are interested in caring for their patients. Those that have adapted to the system realize that they are not dealing with patients but customers. They need to wring every last dollar from them to line everyone’s pocket. It is the primary role of the doctor to generate revenue for the system. If he happens to help a few customers feel better that is a good thing, but not required.

  14. DrWonderful says:

    There will be no substantive changes in health care until the health insurance industry loses it’s anti-trust exemption. As it stands now they can collude and price fix thereby making sure there is no free market competition. They basically lay dormant and rivers of money passively flow to them. That is not good for America and it’s been bad for doctors and patients for quite some time. Repeal the anti-trust exemption for health insurance companies. Their run is over. We’re not selling tires here, folks.

  15. propensity says:

    Vance,
    You forgot to mention the forms, the PBMs, the inane letters reminding you how long a patient should be treated, and the demands of insurance carriers for records to enable a clerk to determine how well you care for your patients.

  16. Qliance Model says:

    Econ 101 – The average salary for IT PM’s is only 85,000 or so a year so I think you might be exaggerating more then a little bit. If someone wants to practice primary care and do it just to make money it is really pretty simple. Stop billing insurance.
    Work on a flat fee of 50 to 80 /month per patient, cut your practice down to 1000 patients (600,000 to 1million gross), get ride of the billers, have longer visits. and do all of the preventive, counseling, hands on care that so many people need and that our society would appreciate.
    http://www.qliance.com/

  17. Popster says:

    I add my support to the marvelous post. We should all think about the implications – and potential to “fix” health care. I should use the term “medical care” because as one of the posters on this blog commented some time ago, it is about medical care and not health care.
    What then can we do to correct the misdirection of current medical insurance?
    1. Pay primary care providers fairly and promptly. Ask not for pre-certification or approval before treatment. Allow physicians to be the final arbiters of care – not insurers, private or government. Give providers the time needed to both understand the patients and diagnose their conditions. NEVER DENY PAYMENT OF A MEDICAL BILL UNLESS FRAUD IS SUSPECTED.
    2. In turn, ask the providers to treat appropriately without the unnecessary MRI’s, studies, tests, and referrals that plague the current age of medical care. Why not ask them? My own experience tells me that providers are more than willing to practice appropriate care if paid fairly and treated as independent professionals who are responsible.
    3. Provide support to help coordinate care (a real weakness among many practitioners). Have backup when that aggressive patient demands the MRI. In other words, be part of an organized support medial community that will work with the patients when necessary and take some of the burden off the physician.
    4. Collect national data on treatment and medical outcomes. Use to the data to inform providers uniformly regarding best practices.
    5. Medical malpractice reform is intrinsic to this model. Treating patients appropriately will reduce the incentive to sue. Won’t eliminate it but will reduce it. Furthermore, since the care coordinating entity is accountable to patients for ensuring appropriate care, liability is, in my view, also shared. Just another example of having someone cover you back.
    Implement these suggestions and we can change the practice of medical care for the betterment of patients and providers. It seems a win – win to me.

  18. lurker says:

    As a primary care physician of 17 years’ experience, I have little to add to Dr. Harris’ post: every clinical situation he describes is one that I and my patients have lived as well.
    The problem is that, although we PCPs save “the system” money, “the system” is completely indifferent to cost savings. In other words, who cares? Certainly, my incensitve to care can’t be financial, the patient usually wants the expensive testing and the insurance company is only rewarding shareholders for keeping its medical loss ratio low.
    The anwser to this problem in the 80′s was capitation, which certainly was a logical approach. However, in the eyes of the public, the role of the PCP was diminished to that of “gatekeeper” who made money for denying services. Also, PCPs were still totally liable for denying services (of course). So the public relations aspect of capitation didn’t work out too well.
    I think the only answer here is to shift payments to reward cognitive services over procedures. This will no doubt start some very ugly internal warfare in the medical community, but I think that’s inevitable.
    Claudia: the most valuable consultations I’ve ever gotten for some patients has been from the person involved with treating their mental health. Of course, these patients had authorized their doctors to speak with me. So much psychological illness masquerades as somatic complaints. After I see a certain amount of negative testing, I know there’s going to be an anxiety disorder at the end of the road rather than the oh-so-fascinating medical zebra.

  19. validity says:

    Send this to Congress and the big O. Hand deliver to the Vineyard.

  20. Christina Marlowe says:

    To all the [health care] industry whoring politicians who are lying, treacherous and, of course, in cahoots with the industry titans:
    When my private (and expensive) health care “insurance” company dropped me, citing my illness as not only pre-existing but excluded from coverage anyway, I had to go onto Medi-Cal (California’s Medi-Caid program) and Medi-Care. Both are government-run programs. Both are excellent. I couldn’t be happier.
    It just amazes me that a full and startling half of all Americans are not only completely uninformed but so, well, so unbelievably stupid. Each one of these idiots shoot themselves in the foot every time they cast a vote and none of them even realize for what or for whom they’re fighting. Is it that they really want to keep the health care industry CEO’s, CFO’s, et al raking in billions of dollars for themselves, while they, these morons, keep paying more and more for (increasingly) ABSOLUTELY NOTHING?!?
    If I was mean-spirited I would wish for them, that is, for each one of these idiotic Republicans, to have a serious and/or chronic illness which would not be covered by their wonderful (preposterous) health care “insurance.”
    By the way, if people have not figured it out yet, I’m happy to spell it out here: [Profit-driven] Health Care “insurance” is one of the biggest and most profitable SCAMS in history…
    The (mostly) Republican politicians are greedy, thieving, self-centered and quite hypocritical while the Republican citizens are incredibly stupid and self-defeating.
    Cheers,
    Christina Marlowe

  21. MD as HELL says:

    Christina, you ignorant ingrate.
    Both Medicare and Medical are “excellent” because you paid NOTHING…everyone’s dream. Every free lunch is excellent. Those excellent programs are going broke because they had no actuarial foundation.
    If your condition was pre-existing, you knew that. What are you mad about? It is not insurance if you can sign up after you are sick…it is fraud. You cannot get flood insurance on the coast of North Carolina when the hurricane is already eroding the beach. What makes you think pre-existing conditions should be covered? If you had no insurance before, it was poor planning on your part.
    Next you will want life insurance without underwriting.
    Do you not realize this is all about more revenue from people who at this time choose to not pay for insurance? Those already paying are already paying. Watch out, young and healthy people. You are the next contestant on “The Tax is Right”.

  22. MD as HELL,
    There is something I don’t quite understand. I may be totally misunderstanding your posts, but at times it seems that you don’t necessarily believe that the young and healthy should purchase health insurance. On the other hand, you just said above that you shouldn’t expect to be able to purchase insurance after you get sick. So what exactly is the optimal time for one to buy health insurance?

  23. J Bean says:

    MD:
    You are actually having some reading comprehension trouble there. Christina was dropped from her insurance when she got sick. It happens. People also lose their insurance when their employers stop buying it, when they get laid off, when a spouse retires or dies, and when they get divorced. Then, if they have a pre-existing condition, they are in trouble.
    Cnristina is lucky, because she has been paying for state-sponsored disability insurance her entire working life. (Socialized disability insurance … ooogah-boogah … scary!) Now that she is sick, she qualifies to collect it. It’s not “free lunch”, it’s the way “insurance” works. If, god forbid, your house were to burn down, your insurance would pay to rebuild it. Meanwhile, I’d be paying for homeowners insurance on my own, perfectly intact house. You wouldn’t be getting a “free lunch” at my expense, either. By your standards, it appears that anyone who is too sick to work should just die.

  24. jd says:

    MD as HELL, you outdo yourself with stupidity in this thread. “No fee no service?” Really? You mean like the horrible Mayo Clinic and Cleveland clinic? What about the many millions of salaried employees working in productive and profitable industries across the United States? You don’t even have a point, just bile.
    As for Christina, I’m not sure her story is true, but if it is: of course she paid for MediCal and Medicaid; they are funded through taxes. She indicated she had a job before she got into medical/financial trouble, so she has paid some if not all of her coverage through taxes.
    Incidentally, for her to say that MediCal and Medicaid are excellent is a little strange. As we all know, they pay so poorly relative to other forms of insurance that physicians often avoid these patients or refuse to see them entirely. I’d like to know more about what was so awesome…low cost-sharing?
    And Christina, you are out to lunch on the profits of insurers. Private health insurance has become (once again) the scapegoat in the health reform debate, and you are just along for the ride. It is not even remotely one of the most profitable industries in the US. Average net income (profit) is around 3%. Compare that to Big Pharma at 17%. Also compare it to the hospital industry, also around 3%. The average profit margin for all US industries is over 5%, so health insurance is a sub-par industry for profitability.
    I remember the dog days in the run up to the Iraq war when we were being fed dubious rationales for invasion. Hyperbolic, paranoid thoughts were presented as though they were the shrewd conclusions of deliberate people. I felt like we were sliding into a dark age, and so I joined the Howard Dean campaign and spent the next 9 months of my life devoted to electoral politics because I felt like I had to do something. In some ways, the vilification of insurers now feels quite similar to me. But this time the Left has lost its way and is working itself into a self-righteous rage to remove private insurers from the face of the earth.
    It isn’t as sinister, but it is as misguided, unnecessary and ultimately probably self-destructive. I’m proud to say that I’m one of the very few to have not lost my mind in either of these episodes.
    More cortex, less amygdala.

  25. Excellent post, I would add that this plight affects most of medicine, not just primary care. Try explaining my call schedule of every third night, an average work week of over 100 hrs, caring for the complicated post-surgical patient for a single fee for 90 days where I sit at the bedside for nights on end neglecting my family and personal life, assuming care for anyone in the ED and treating them exactly the same regardless of insurance or legal status…the hourly reimbursement would shock any worker….but I wouldn’t trade it for anything…and therein lies the problem.
    We are the easy targets because as long as we relish our art and hold to the altruistic motives, our apparent worth to society will continue to diminish. It is beyond logic to understand why we continually bear the brunt of cost-reduction, when the insurance and pharmaceutical executives would never budge from their salaries..and worst of all they are not even being asked to.
    Its time to wake-up docs. If we don’t join our collective voices and press the true value of what we offer to the health care collective, then we deserve what we get. Unfortunately it may be too late.
    reformplan.org

  26. PA in Montana says:

    Dear Dr. Vance,
    There are probably a few really good PAs who are taking new patients in California right now, and who could care for you with excellence not found in recent MD grads…
    One cannot perpetuate the same arrogance and bull shit that is bringing you down and blame somebody else…yeah, the system is broken…we all make less than we made 20 years ago…may we find a way to get health care for all…in spite of the arrogance of medical professionals (like guess who?) who believe their years spent in medical school equal excellent care for human beings.
    I know many mid-level practitioners doing brilliant and compassionate work, just as I know many MDs who fail to pass the tests required of humans to treat other humans well.
    So complain, if you like, but don’t put down my profession. It makes our battle even harder. It turns those of us providing primary care against each other…and guess who wins? (not the people, not the primary care providers, be they MDs, PAs or FNPs) but the same status quo insurance companies that have been dictating health care for many years now.
    The death of primary care?

  27. Jitesh Chawla says:

    In response to Economics 101′s comment, I think the reason a lot of doctors don’t go into Family Practice or Primary Care is because it is easier to let someone else deal with the headache of “being on the frontline” with patients’ call for narcs, etc. while being paid much more.

  28. Durask says:

    Well, $75 is not bad at all. If you were a Canadian primary care doc, your fee would have been around $40 canadian dollars and that’s with higher taxes. We all know how wonderful Canadian system is so cheer up and look forward to getting paid $35 for the same work in a few years time. :)

  29. MD as HELL says:

    Margalit,
    I believe young people should have health insurance. I do not believe they should be forced to have health insurance.
    A young person can buy an individual plan for about $120 per month. That is a lot of money for a 22 year old male who is unmarried and not likely to ever need anything major. That person runs a small risk which he can choose to take or can choose to buy coverage.
    The government wants to force him to buy coverage. The only reason they want to force him to buy coverage is to get money from him that is not a “tax” in the political sense. He will likely never need to use the coverage.
    My point is freedom of choice. Freedom from government.
    Freedom.
    The ideal time to buy insurance is when your health and costs might impact your spouse or child. In addition, women should buy insurance when they may become pregnant.

  30. Nate says:

    “Christina was dropped from her insurance when she got sick.”
    This is a complete and utter lie unless it happened 15 years ago. The ONLY ways for an insurance company to drop an individual is to pull out of the state and stop offering insurance to all of those policies. The second way is fraud, if she lied to get coverage in the first place then they found out they could cancel her. It did not happen like she is trying to lead people to believe.
    “Then, if they have a pre-existing condition, they are in trouble.”
    Again with HIPAA and various state laws this is just no longer true. There is a very very small % of the population that wants insurance and is denied and even they almost always made mistakes that created the situation. Your chastising a system for short comings that where fixed 15 to 22 years ago.
    “It’s not “free lunch”, it’s the way “insurance” works.”
    Actually that is not how insurance works. What we pay for Medicare is a tax to pay benefits for existing policy holders, it is by no means premium for our future benefits. This is evidenced by the fact today’s premium could not even begin to be covered by what beneficiaries paid in premium. Even with Obamaesqu return projections what today’s seniors paid in “premium” would not buy them half the coverage they have today. MD’s argument is still accurate that if you paid premium for your standing house and MD waited till his burnt down you would be upset if the insurance company sold him a policy, rebuilt his house, then raised your rates.
    “A young person can buy an individual plan for about $120 per month.”
    Actually they can buy one for $40-$50 a month. Since they are young and healthy the smart thing to do would be to buy an HSA for $40 a month and then put $20-$30 a month into the account and start building it up. If people saved in their younger years we wouldn’t have the financial issues in our older years. Before Medicare passed 85% of seniors had enough savings to pay for all of their healthcare, that is a scenario we need to return to.

  31. juan says:

    Brave words. all this reform has come to a point where i am seriously thinking about leaving the US just for health care, A friend did it already and he had a tremendous success. see more at http://www.truthaboutmedellin.com/medical.html

  32. Christina Marlowe says:

    MD as Hell is quite obviously a brainless thug–probably lobotomized in the late 1970′s, and then injected with venom. Probably carries a gun, too. You see, I live in a world, Mr Mad as Hell, where people help each other. We are kind and compassionate, and yes, we all work hard; we walk the walk while you and all the others just like you, are devils incarnate, if you believe in such nonsense. Yes, you are plain evil and really quite hateful. All of this is truly your fault, all of it. Blame yourself, you idiot, because you certainly cannot blame ME. Furthermore, Mr. Mad as Hell, as you burn in your own stupid and blind fury, I, on the other hand, enjoy thoroughly the world in which I live. It really is a very happy place as I chose to keep people like you where you belong: in your very own, self-made gutter.
    By the way, I don’t believe for a second your rap about god and Jesus and all of that other hypocritical right-wing garbage; you see, I AM A PERFECT HUMAN BEING!!
    Moron.
    Cheers,
    CHRIST…ina Marlowe

  33. MD as HELL says:

    Christina,
    You are due for your Haldol shot.

  34. Amanda S. says:

    This is a very good post. You make a great point about patients. We are anxious, always expecting the worst and demanding unnecessary treatment. In actuality, after a good physical exam, a doctor can give you a pretty good idea about what’s going on.
    As a patient, I always have this desire to be immediately diagnosed, and I can see your point about how primary care is dying. I’m sure people are thinking why go to my primary doctor when I can have an MRI, X-Ray, etc. done right away … if I go to the ER?
    Of course, I would never go to an ER before seeing my primary care doctor, but I know a lot of people who do. It’s a waste of money, in my opinion.

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Yes. We're looking for bloggers. Send us your posts.

STORY TIPS
Breaking health care story? Drop us an e-mail.

CROSSPOSTS

We frequently accept crossposts from smaller blogs and major U.S. and International publications. You'll need syndication rights. Email a link to your submission.

WHAT WE'RE LOOKING FOR

Op-eds. Crossposts. Columns. Great ideas for improving the health care system. Pitches for healthcare-focused startups and business.Write ups of original research. Reviews of new healthcare products and startups. Data-driven analysis of health care trends. Policy proposals. E-mail us a copy of your piece in the body of your email or as a Google Doc. No phone calls please!

THCB PRESS

Healthcare focused e-books and videos for distribution via THCB and other channels like Amazon and Smashwords. Want to get involved? Send us a note telling us what you have in mind. Proposals should be no more than one page in length.

HEALTH SYSTEM $#@!!!
If you've healthcare professional or consumer and have had a recent experience with the U.S. health care system, either for good or bad, that you want the world to know about, tell us about it. Have a good health care story you think we should know about? Send story ideas and tips to editor@thehealthcareblog.com.

REPRINTS Questions on reprints, permissions and syndication to ad_sales@thehealthcareblog.com.

WHAT WE COVER

HEALTHCARE, GENERAL

Affordable Care Act
Business of Health Care
National health policy
Life on the front lines
Practice management
Hospital managment
Health plans
Prevention
Specialty practice
Oncology
Cardiology
Geriatrics
ENT
Emergency Medicine
Radiology
Nursing
Quality, Costs
Residency
Research
Medical education
Med School
CMS
CDC
HHS
FDA
Public Health
Wellness

HIT TOPICS
Apple
Analytics
athenahealth
Electronic medical records
EPIC
Design
Accountable care organizations
Meaningful use
Interoperability
Online Communities
Open Source
Privacy
Usability
Samsung
Social media
Tips and Tricks
Wearables
Workflow
Exchanges

EVENTS

TedMed
HIMSS South x South West
Health 2.0
WHCC
AHIP
AHIMA
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