Simming at work and why

I figure that some of my comments regarding the use of a simulator as a minor method of escapism at work warrants some elaboration.

Bear with me, this all works into the mix.

Yesterday, now former, US Congressman Randy ‘Duke’ Cunningham resigned his post in the midst of an incredible scandal that had him immersed in a scheme of payola for favors given in the form of steering contracts to specific defense contractors. What makes this all the worse in scope is that Cunningham not only admits that he did it but that he had everything going for him before he lost his focus in life.

You see, Randy Cunningham happens to be a Vietnam War hero. He is a retired Naval Aviator and a MiG ace during the Vietnam War. There are not too many aces out of that conflict so he happens to be in pretty rare company. Given that he had this as one of his credentials as well as a commission in the United States Navy, you would think that Mr. Cunningham would have been able to live a productive an honorable life.

The life of a US Congressman is not bad. You make a good base salary, well, good if you plan on maintaining a home in your own district and not falling prey to high priced condos in the Watergate or Falls Church, and you have a remarkable and probably grossly overdone health plan and retirement. I suspect that the bottom line in this package is that Congress wanted to make sure that people who serve in congress would not have financial worry at the top of their list presumably so that they could legislate in an impartial fashion.

So add it up, military retirement, Congressional pension, salary, notable resume’ and respect as a war hero, the question remaining to be asked is “Why?”

For that answer you are going to have to ask Mr. Cunningham. I do not have the straight shot into his brain and only he knows what happened on the way to the slop trough, but whatever it was it is symbolic of a good many problems we are facing in the country today.

Figure this, I spent 5 years in college, 1 year in graduate school, four years in medical school, a year in internship and three years in residency to finally arrive at a place where I spend the bulk of my day taking care of people who utilize an emergency room for the ‘convenience’ that it offers. I kid you not; I am told several times a day that people come to my ER because it is convenient. They do not come because they have an emergency, often it is nasal congestion or the desire to find prescription narcotics, but it is always because of convenience.

While people like Mr. Cunningham are busy being wined and dined by folks who will end up selling the Army and other services things that not only do we not need but actually increase our risk on the battlefield our nation’s health care system is spending billions of dollars to support people who go to emergency rooms because it is convenient. That is why we cannot balance a budget and why we cannot seem to get a sensible and affordable health care system. The people who we trust to come up with workable solutions are too busy getting whatever payola they can get apparently because the relatively lavish salary afforded to them by the US taxpayer is insufficient for their basic needs. It is an abomination.

I have patients come in to my ER every day that are spending your money and mine in the form of Medicaid and Medicare who no longer feel the need to have a family doctor. The ER is too convenient and it is made all the more convenient by the fact that the system does nothing to monitor or police the utilization of the emergency rooms of the nation. I used to think that in Columbus there was a group of people who might actually monitor the number of times that a Medicaid recipient went to an emergency room. I figured that the same people might also compare that to the number of times that they visited their family doctor. Doom on me for assuming that a system that spends billions of taxpayer dollars would have such oversight. Doom on me because it doesn’t have anything of the sort.

With one card my bank can tell me exactly on what, when and where I withdraw cash and spend my money but the systems that spend 1/7th of our nation’s economic wealth have nothing of the sort and you know why? I hate to be a cynic but I had a very enlightening conversation with a former social worker about this. His quote to me was, “There is no drive to police the system because that would affect caseload and if you kicked people off the system you would require fewer case workers and therefore the social workers might get laid off.” Why doesn’t every person who is a ward of the taxpayer have a smart card so that somebody can track the metrics of their behavior?

My sister who works for the state of California, a state swimming in Red ink along with millions of undocumented workers, voted against the ‘absurd’ proposals of Governor Schwarzenegger. Proposals that would have allowed greater ease in the hiring and firing of state workers to allow for better tailoring of these workers to the needs of the state and its budget. Why? “I am not going to vote myself out of a job.”

In a word we are screwed. All of us. Why? Look at Star Wars Episodes I and II and notice the comments of Senator Palpatine about Bureaucrats and who runs the show. In my experience George Lucas is not a brilliant storyteller he is a great moviemaker but all of his themes are generic to what we now face. That is why he appears to be the great storyteller. He is telling us all exactly what we already know and we buy off on it as creativity.
Picture a job where you spend every day listening to people complain and most of them don’t do even the basics of helping themselves before they run off and spend a lot of other people’s money to get ‘help’. When I was a child my mother stored St. Joseph’s childrens aspirin by the bucket load. We didn’t go to the emergency room for anything short of potential loss of life or limb. Today, people on Medicaid arrive with card in hand ready to shoot the moon on the most expensive health care on the planet and yet many of them register with no assigned family doctor. The excuse is always the same, “I cannot get in to see a doctor.” Which might well be true since it is less than desirable to have a waiting room populated with people who smoke, seldom bathe and consider dental hygiene as an optional item in the personal maintenance department. No family doctor wants the rest of his patient’s offended by loud, vulgar and smelly people.

The irony is that entire programs like WIC and the like shower ‘freebies’ onto this population and yet not once during the course of the receipt of what many of us refer to tongue-in-cheek as the “magic kingdom card” are any of these recipients required to demonstrate even the remotest understanding of basic health care and personal hygiene. We educate basic MARINE corps recruits in far greater detail of how to care for oneself personally than we do people that we hand over subsidized absolute personal autonomy when by demonstration of needing public assistance they have shown that they cannot handle the same.

And this is what really upsets me about Mr. Cunningham and so many of his colleagues. We feed people ‘fish’ all the time with our massive social welfare system. We seldom teach people how to ‘fish’ for themselves. When was the last time you saw a public service announcement? Long time ago right? Well the reason for that is that in the late 1990s the federal government got out of the business of protecting its citizenry through the education of its citizenry. Education takes time and election cycles are short. The bang from the buck comes at throwing money at something in the short term, to afford re-election so that more money can be thrown.

It is killing our nation. It is killing my spirit. I find myself ruing the days I have to spend in the ER because I am constrained by the requirement that I ‘rule-out’ bad things. ‘Ruling-out’ costs a boatload of money. Some person who doesn’t hold a job and spends days on end sitting at home ‘worrying’ about life to the point where they get chest pain walks into my ER. I am required to make certain within a reasonable standard of care that they are not having a heart related problem. My ethics as a physician and Christian demand it, lawyers will skewer me on the day when I miss one and the system has no other viable alternative for keeping these people out of the ER. So countless times a year I spend a boatload of all of our money to cover the remote possibility of a problem and countless times a year I find nothing. Why?

Because it is other people’s money.

There is no fundamental impetus to change the system to work because there is no vested interest on the part of the policy makers to make a workable system. The bureaucrats don’t want to lose their jobs and unless they happen to succumb to some horrible illness and endure the nation’s absurd method of delivering care they have no reason to think that anything needs to be changed.

What changed me? I used to be the total free-market health care guy. The government can never fix the problem the way that the free market can. Then I found out that I was wrong. The change occurred when I spent a year on active duty and actually encountered Federal Health Care.

There are a couple of premises about federal health care that have to be employed for the system to work;

1. There is a control over what is given and how and when it is given. Now this smacks of rationing. Why? Because it is. The military has long recognized that everyone cannot have a full body CT scan every year just to get “checked out”. It has to take care of the most people it can for what money it is given. So it rations based upon what works for most people. Do some people fall through the cracks, yep, but the VAST majorities of people get quality care and do very well.

2. The people that it takes care of will be healthy. The military population is generally healthy. Why? Well first of all you have to take a physical fitness test every year. No questions. You have to do it so you work out year round. Second, if you use drugs you get thrown out. Third, families are encouraged and supported so that they are helped in terms of staying in tact. The military pours a lot of money into housing and funding programs to support families. It does so because a healthy family is a good thing. You do not get benefits in the military if you shack up. You have to be married to live together in military housing and get benefits. This leads to more stable and healthy people in general.

3. People will be affected by what they hear. The military through Armed Forces Network puts out a lot of public service announcements. These deal with all manner of topics from alcohol and driving to how to properly cook meat during the holidays. They are very ‘1950’s’ in their production and because of this they are humorous but the bottom line is that once you see one you remember it forever.

So the military has accepted rationing, demanded personal accountability and recognized the importance of educating its people as a part of the formula for controlling costs. Overall it is a very good system. It is everything that US civilian health care is not.

The reality is that the US civilian health care system is not a free market. A free market is a situation in which a person has a choice between a Honda and a Toyota or nothing at all. Medicine is a choice between life and death and so practically speaking it is not really a choice at all. There is nothing free-market-like in a person who is having chest pain. That is why a patient is not a customer. Customers have choices; people who have life threatening illness and are insured by someone else have no choices. They get what they get. The sooner we learn this the better we will be. Unfortunately, the vast majority of hospital administrators, who are not medical people, still look at health care like they look at the local mega-mart. Nobody in his or her right mind goes to a hospital to shop. There is nothing in a hospital that anyone really wants to buy. They end up there because they have no choice, really.

Now back to Medicaid. For all the frustration among those of us who do not have the luxury of shopping for our health care, you should be comforted to know that Medicaid recipients have none of that because of our taxpaying generosity. Are you angry because you are in a PPO, HMO or some other alphabet soup organization that determines where, when and too whom you will go? Well join Medicaid because there is nothing short of a few paltry attempts at managed care in that system. Yep, the people who have everyone else paying their bills can go anywhere they choose, at any time, including the emergency room because it is ‘convenient’. Now I don’t know about you but I am fighting mad at this system. I spend the better part of my free time trying to pay my taxes and do things the right way and I am forced to pay for an entire class of people who do nothing to tae care of themselves.

The only thing that prevents revolution while Mr. Cunningham et al. are busy doing everything for themselves and nothing for the nation is the fact that most US taxpayers assume that the program really works and that there are literally hidden hoards of people out their who cannot get health care without the bloated and mired bureaucratic messes known as Medicaid. Take it from me; the hidden hoards do not exist. They just do not. Anyone at any time can come to an ER regardless of ability to pay so the false argument of all these people out there without access to health care is just that, false. Everyone has access, but not everyone has someone else paying the bills. I know this because every day I work a good fourth of my patients have no pay source. Meaning that they will pay $5 a day, or not, till they die to pay for an ER visit that costs $400 to give them a decongestant for an earache.

Now oddly almost everyone I see smokes and has a cell phone, but they cannot afford the $50-75 for a physician office visit, but they can afford the ER visit? Come on! Do the math.

So in the end we are playing politics with something that is going to bankrupt us all. Say goodbye to private insurance in the next 10 years, or say hello to the kind I carry, a medical savings account with a $10,000 deductible. I pay $250.00 a month for that coverage with a prescription drug benefit because I can afford the doctor visit for my kids a couple times a year (I don’t burn up $150 a month in cigarettes at a pack a day) and if heaven forbid someone in my family gets cancer then I can cover their massive bills with $8 million benefit and make payments on the 10 grand.

So what is the solution? Pretty simple. Two part health coverage. One private and one public system. In the private system you pay for the coverage out of your pocket and in the public system you take the rationing and the realistic triage (in the army I didn’t put soldiers without fevers or evidence of infections on antibiotics, I sent them back to work) that will send people home who don’t try basics like a Tylenol first before coming to the hospital. Send them home BEFORE they rack up a bunch of money in charges that someone else (read we the taxpayers) will have to pay. We’ll pay taxes for the public system and you will wait your turn. The Congress will have to baseline budget it as well. They must fund it at a certain predictable level and not mess with it. No more Mc Medicine. In the private system you can have a new hip tomorrow but you bettered cough up the $50K today. That is the only solution and it should have come a long time ago; long before people got the idea in their head that health care is a right. Problem there, rights are things that require no other person to guarantee; they are granted by God or Natural Law and are not contingent on others, in fact they cannot be contingent upon other people or else they are not rights, they are privileges. Unless you happen to be a physician and even then state medical boards frown on self-prescribing, health care cannot ever be a right. (We can discuss the failure of the public education system, as exemplified by a people who cannot clearly define rights and privileges, at a later date ;) )

Because people believe that it is a right, they expect it for free and believe me, I spend the equivalent of a brand new Hummer H2 daily in my little ER so it is far from free. Thankfully I have a lot of friends who are doctors so when the day comes that I get sick and the system is collapsed, because people like Randy Cunningham were too busy worrying about other people’s yachts and selling their over-inflated luxury homes to be concerned with fixing health care in the country that they swore to look after, I will still have access.

The rest of America, if it doesn’t start taking an interest in the system, will be out of luck and out of time.

So it is because of this that I find some solace in having the sim run at work, the view over the Rockies, virtual though it may be, is still a far better horizon that the one that I see right now if I focus on my workplace.

9.5 million people 85 years old and older by 2010, and growing, in the United States. Do you have any idea how much money it takes to keep an 85 year-old heart attack victim alive? A LOT. Not that we shouldn’t but the current system will not be able to sustain that delivery for long.

Get involved and demand accountability and a common sense solution from your elected leaders. It is the best insurance you can find.

FF