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PostPosted: Thu Sep 02, 2010 5:09 am 
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Joined: Wed Nov 27, 2002 1:16 am
Posts: 2758
Location: Boston
"everyone will be treated that we want to treat based on the established PC criteria"

Actually, there are pretty clear criteria. For weird reasons, you can get almost anything in a hospital, but if you're not sick enough to get in, the poor get transient care in the ED (and don't pay) and struggle to get their meds and needed procedures. Once you're sick, or poor enough (or your disease is "special," and I don't mean PC categories; rather, kidney failure is the best example) then you're set up at least with medicare. But that reimburses so poorly people still have a hard time. I work at the "city hospital" and we don't take medi-cal the public insurance (CA's medicare). Our clinic won't book you unless adminstrators make an exception; they refer you to community clinics. This is because we already have a huge load of underfunded people and don't want more, because, in the world we all live in, the hospital has to protect its bottom line not just "do the right thing."

Many of my patients get admitted because they're disabled by their illness and then, because of that illness, they're now medi-cal eligible, so I fill out their paperwork and the hospital tries to help them get it so they get paid retrospectively (not well, but more than zero). If you're not sick enough, especially if you're working poor, without benefits... that's tough... not a good spot to be in. Often our financial counselors will advise people to "spend down" assets so they qualify for public assistance.

The whole thing is very weird.

Malpractice is a very long and complex story... can't really clarify how that works in a post or two. Well, I can only make a few comments on cost and insurance too, but... I'm tired.

As for your doctor's transcript... well, interesting request. I would not think my grades from 10 years ago factor into daily care very much. I HAVE noticed that my performance is predictable. I got the same score on all three steps of the USMLE, for example, taken > a year apart. So maybe that's something.

But you don't want to know how your doc scored in pathology, on the few questions out of billions s/he could have been asked. You want to know if they have the right therapy for you today. That may require looking something up. I am happy to tell anyone, including my imprisoned or homeless or any patient, without assumption, WHY I recommend certain blood pressure medicines. I notice they're on atenolol for example, and I explain beta blockers aren't first line choices for blood pressure and can cause more fatigue so I save them for specific indications like after heart attack. I explain atenolol doesn't last 24 hours and leaves people under treated in the AM when most heart attack occurs. I point out in careful literature reviews that it has not shown a survival or event benefit in relation to other betablockers. I mention what the JNC-7 guidelines are for treating blood pressure and share with them results of recent trials like the one finding normalizing blood pressure didn't help diabetics. If they want, I show them articles. Then I mention what these things cost at Walmart. Grades are cool but medicine today isn't about (shouldn't be about) prestige, gray hair, attitude, or any of that. It's "show me the data!" plus familiarity with guidelines and a bit of experience and judgment.

Besides, medical schools are all moving to Pass/Fail for basic sciences and vague "honors" "high pass" "pass" for clerkships, where 60% of the students may get honors. Some places, like Harvard, don't permit the AOA honor society -- all their students are exemplary, doncha know. Some of my cool accomplishments from medical school are impossible now, and certainly irrelevant, even to my patients or potential employers, etc.

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--Ian


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