Die Slow
Standard ≠ Optimal
Painfully Gorgeous
“I think my wife’s cheating on me.” he said as he dumped his gear on the floor.
He was more dishevelled than usual, looking like he had a particularly long night.
“Seriously?”
“It’s just a feeling. She’s got this personal trainer…”
“How much sleep are you on?”
I reached into my bag to grab a bottle of water, as I came up, he jammed his phone in my face. Wife on the screen, naked. Sprawled out. I now grasped the source of his suspicions.
He had gotten married a few months prior.
“Nice. You gonna get to work?”
“I met her at salsa class. I’m signing up again. You should come. Don’t forget volleyball on Sunday.” His speech racing.
“You good?”
“I took some of her thyroid medication”
“WTF. Why?”
This conversation continued for far longer than it should have and got progressively more outlandish. He proceeded to inform me there was a shootout on his street, and he had purchased a gun for protection.
He was a solid physician with a good heart, running on fumes. A Huey Lewis fan. We’d bonded over Back to the Future, the soundtrack, and what date that rocket would land after gunning past a smouldering 99.
We played volleyball that Sunday.
For that Bread and Butter Insurance Will Leave You in the Gutter
In 2013, plaintiffs sued Blue Cross Blue Shield, targeting more than 35 BCBS plans, alleging the companies carved up the country into exclusive territories and agreed not to compete — driving premiums up and choices down. It ended in 2022, a $2.67 billion settlement. No admission of wrongdoing.
UnitedHealth took a different route — Auto-Deny. Its subsidiary NaviHealth built an algorithm, nH Predict, that estimated how long a patient “should” need post-acute care — then coverage was cut to match the prediction, over the objections of the patients’ own doctors. The families of two deceased Wisconsin men took it to court. When denials were appealed, 90% were overturned. They knew only about 0.2% of patients would ever appeal.
Live by the Code
Radiology and pathology are binaries. Either there is a pathology present or not.
Surgery. Either you are operating or you aren’t. You can see surgeon success rates.
Transgenderism and genital mutilation are abominations.
Psychiatry — getting ‘help’ from someone who doesn’t know the difference between a man and a woman is insane.
A drug dealer giving amphetamines to a child — Jail.
Amphetamines for childhood ADHD — Standard of care.
Anything involving direct contact with patients revolves around the physician’s ability and willingness to immediately administer drugs. Physicians do not get paid for treating or curing patients. Physicians get paid for generating billing codes. Patient outcomes have almost zero impact on physicians’ earnings.
Insurance companies own the physicians. You are the billing codes that you can produce.
If the physician spends more time with a single patient attempting to improve patient outcomes, they will be rewarded with less pay and even less free time. If this behaviour persists, shortly thereafter, they will be paid a visit from accounting.
Standard of care is the only metric, and it doubles as a liability shield.
The hospital is a business, and it reports to accounting. Accounting does not track patient outcomes.
Doctors are compared and ranked based on the number of codes generated. If a physician is seeing fewer patients per shift, they now have a problem. Quickly reprimanded. The physician is permanently under a time crunch to rack up high patient counts.
This is a volume game.
Amphibolous Care
Physicians learn the rules of reimbursement. How far documentation can be stretched before regulators intervene. The goal is to a) satisfy insurance companies and b) not get sued. Both are achieved by following protocol.
If a patient gets better, great. If they deteriorate — did you follow Standard of Care?
Standard of care means pills made in China, India, etc. Indefinitely.
Five drugs or more is polypharmacy. One in five Americans qualify. In 2020, 6.3 billion prescriptions were filled — nineteen for every American.
Scripture has a word for this: Pharmakeia (φαρμακεία).
The average patient is obese, has diabetes, high blood pressure, and coronary artery disease. The assumption is that the patient is incapable of modifying their behaviour. They are considered helpless. Pharmacologic intervention is assumed to be the only viable option.
Optimal care requires modifying hundreds of daily choices. Sleep, nutrition, lifestyle.
These are addressed with the patient in a disclosure ceremony before pulling out that prescription pad.
In-Group Referral
“In multiracial societies, you don’t vote in accordance with your economic interests and social interests, you vote in accordance with race and religion.” — Lee Kuan Yew
Physicians are not immune. Healthcare is tribal; referrals are often also made in accordance with race and religion. Doctors often refer within their own in-group. Not the best specialist for the patient.
Referral doctors send patients with an understanding. If the expectations of the referral doctor are not met, that referral stream will end and be directed elsewhere.
Finding the best specialist is the patient’s responsibility. This is not disclosed, and if it is, the best specialist is often not covered by that patient’s insurance.
Ask a top specialist what they would do in any given patient’s shoes, and often, it is completely different from the current standard of care.
End of Life Care
I loved my grandmother.
Visiting her in long-term care one day, I noticed she’d developed oral tics. I asked nursing for her medication list. No psych meds present. I asked them directly whether she’d been put on an antipsychotic. They denied it. After continued prying, the tics eventually disappeared.
Later, she was put on morphine. She eventually couldn’t eat or drink. They lowered the dose — excruciating rebound pain.
I arrived one morning, stepping off the elevator, I could hear yelling. I walked down the hall toward her room. I didn’t recognize my own grandmother’s howling until I reached her doorway. I asked nursing how long she’d been crying out. They weren’t sure. I asked when their shift had started and if she had been crying out the entire time. Over three hours. Unattended.
She kept asking for water, but every sip made her choke. I sat by her bed with a straw, dipping the tip in the glass, pinching the top to hold a few drops, and coaching her through each swallow sequence so she wouldn’t aspirate.
My family visited in shifts. The staff simulated sympathy.
They killed her.
Slowly.
