Numb and Numb-er

I’m happy to announce that I now drive a Mercedes-Benz.  It’s true.  A real in-the-steel-and-glass Mercedes.  The model is a C-180, which is the 4-cylinder, 4-door model.  The smallest engine they make (great gas mileage).  To boot – it’s green, my favorite color.

I’m a doctor now, people.  Apparently helping sick people entitles me to the high-life.

Truth is, here in Germany, the term “hooptie” is a known, legitimate noun.  The term is used to describe nice German cars that are (usually) bought by Americans and then run into the ground.  You can pick up BMW and Mercedes hoopties for 500 euros.


Mine looks just like this one...but way cooler.

My car isn’t exactly a hooptie.  In the States, it would probably have cost at least $5,000, maybe more.  I don’t really know because I’ve never been in the market for Mercedes-es.  But I got mine here for a few thousand bucks.  It’s still in good shape and as long as I take care of it (an expensive proposition in Germany), it should get me around for at least a few years.

That is…unless it takes a few years until my new monument to affluent living is allowed to take me anywhere.

Take the Army’s torrid and longstanding love affair with bureaucracy and combine it with 1000 years of rulership of the masses in Europe, you get the process I dealt with just to be allowed to drive a car.

Buying the car is easy.  But in this Germo-Americo Funkenthink, the quagmire starts there.  You first need a special driver’s license, which requires a half-day class and then a 130 question test ( which I immediately failed by about 15 questions).

You also have to have insurance on a car before you actually register it.  And, the car needs to be inspected.  But you can’t drive it to the inspector’s unless you have it registered and insured.  But if you fail the inspection, you’ve just registered and insured a car that sucks.  So, you have to de-register it (I did that – twice – before I settled on the Mercedes).  De-registering requires a trip to the local customs office (American) plus a second trip to the other customs office (German, 35 min drive), numerous forms, money, waiting and…all the while you still need the insurance.

So, I’ve been a little reticent to drive much unless I have to.  I’m always wondering if I actually have all the paperwork and proof that will allow me to stay out of jail were I to get pulled over.

Instead, I came up with an alternative (heh, heh):

Through some highly unfortunate events in my brother’s life, I ended up with his Harley motorcycle.  Now, make no mistake – I owe him for this very expensive bike.  It was a ‘take-care-of-my-hoss-for-awhile’  kind of proposition.  Of course, being a deeply loyal brother, I immediately agreed to “help out”.  But, not being a big Harley-lover, I…well, I sold it.  And I bought a BMW motorcycle instead.  Initially, I sold it to help fund out trip out here, and a portion of the Harley money was a HUGE help in getting us here.  That said, I GUESS whatever money we had left over should have been sent back to my saintly bro.  But with all these fantastic German road machines around, you sorta just get Beemer Fever.  What was I supposed to do?

And anyway, my bro is about 10,000 miles from me.  Is he really going to come get me when he realizes I sold his Harley?  I mean, c’mon, I did the guy a favor!  BMW vs. Harley is a no-brainer.


Mine's just a LITTLE less shiny and has panniers.

So I now fly along the German Autobahn on a R1150 RS BMW.  Riding a bike like that, in this part of the world (any part of the world if you worship BMW bikes) is an experience that is hard to replicate.  Harder to describe.  At 80 miles an hour, I blow by stunning autumn trees, taking in their blurred resplendence in shimmering hues of gold and yellow and red.  “My” bike purrs along effortlessly.  When I lean over the gas tank and duck behind the faring, the engine sounds something like a sewing machine, but even softer, maybe more like two feathers rubbing together.

There’s only one problem…Germany is COLD.  The other day I left for work in the dark, road sparkling with frost, at a temp of -2.5 Celsius.  Buh-rrr.  And this is only OCTOBER.

The night before, I had received a notification in the mail that my car did not have the correct license plates due to a dating error in the – you guessed it – insurance policy.  So, should I be pulled over in my esteemed Mercedes for any reason, I could expect to be hog-tied, whipped and sent back to the States crisply folded into a shoe box.

Thus, while my longsuffering wife dealt with the paper-pushers in Hiedelburg, I rode the bike to work, frost and chill notwithstanding.  I do have some decent riding gear I picked up when I first got the Harley.  I have a jacket with armor in the shoulders and arms, and pants with knee and hip pads.  I have big thick gloves – also a “gift” *ahem* from my bro – and good riding boots.  All the gear is made to withstand serious wind and rain.


"Got a little nippy back there going through the pass, eh Har?"

But I’m not sure any gear will hold up for long when receiving a direct 80 MPH sub-freezing air blast for 40 straight minutes.  Mine didn’t.  By the time I got to work, I was so cold most of joints wouldn’t bend.  I walked into the clinic like I was in a body-cast.  I don’t think I even spoke to my first 3 patients that day because I couldn’t unclench my jaw.  I just nodded compassionately with my hands buried in my armpits and gave ’em whatever drugs they wanted.

I probably should have just sold the Harley and given whatever money we didn’t need back to my brother.  But instead I chose to buy a Beemer with the extra cash and freeze my face off in Germany.  If you love BMW motorcycles, you’ll understand completely.  You’ll probably applaud me for such a wise and intelligent idea.

I’m cheering, anyway.

The AMA – Trust At Your Own Risk

Adapted from an Op-Ed in today’s NYTimes by Nicolas Kristof

Some fun facts about the AMA (American Medical Association):

  • supported segregation
  • opposed President Harry Truman’s plans for national health insurance
  • backed tobacco
  • denounced Medicare
  • opposed President Bill Clinton’s health reform plan
  • probably represent less than 25% of practicing physicians, most of which are specialists who dearly want to protect incomes from $250,000/year to over a million per year

Here is their current position on a National Insurance system:

“The introduction of a new public plan threatens to restrict patient choice by driving out private insurers.”

They might have been right about opposing Clinton’s freakish health care plan.  They should have shaped the medicare debate instead of obtusely opposing it, and you can be the judge on the whole segregation and tobacco thing.

I think for-profit medical insurance is morally wrong.  Insurers should not make more money than patients, and not doctors, either.  If you want to be available to help someone in a time of weakness and need…you shouldn’t make 20% returns on them until that time arises.

*Disclaimer:  The AMA is a putrid organization from the inside out (and hopefully will be obsolete in 10 years)…but they do have it right on tort reform.

Another Study

A group called The Physicians’ Foundation came out with yet more evidence (check it out here) supporting what you probably hear from most of the MedBlog community in different forms all the time.  If you read my blog regularly, you’re probably also aware of some of my cyber-colleagues like Kevin M.D., Dr. Wes, The Happy Hospitalist, Fat Doctor, Shadowfax and others espousing similar concerns.

We’ve all talked about how primary care is becoming untenable.  Now there’s a questionnaire survey that was mailed to every primary care doctor in the country, and it backs up our claims too, essentially asserting:

Primary care medicine sucks if you can’t spend time with your patients.

We didn’t go into medicine (and enormous debt) to do paperwork and argue with insurance companies.  People who do paperwork and filing for a living don’t understand our intolerance for their way of life, but it’s a fact that not everyone likes the sterile confines of alphabetization, algorithms and cubicles.

Some argue that the answer is more allied-health providers for primary care, like N.P.’s, Dr. Nurses (weird one, I know), P.A.’s, etc.  I disagree.  Excellent health systems provide excellent health care, and that starts with well-trained providers with doctorate-level education.

Residency-trained family medicine doctors average 12 THOUSAND hours of training before practice.  Nurse Practitioners average around 3500 hours.  Same for P.A.’s.  These people are easily as intellectually-equipped as doctors, but I think the idea that they are as well trained or can replace physicians is ludicrous.

I also hope lawmakers intent on saving our system don’t rush to the EMR (electronic medical record) as the messiah of American medicine.  It isn’t.  I use one every day, and it does very little to improve care and absolutely nothing to improve efficiency.  If EVERY doctor used an EMR that talked to all other EMR’s, efficiency might improve somewhat.  But our capitalist system has provided us with dozens of competing companies and, given our obsession with medical privacy, none of these programs communicate with each other.  Digital charting takes hours and is only slightly improved by hacking away on the keyboard during the entire patient encounter, detailing everything as it happens.

And, for a future blog, those records do nothing to protect doctors from litigation.  Trust me.  Nothing.  If anything, they help the plaintiff.

Also on the EMR topic, it is colossally more expensive to sustain than just some basic paper and dictated notes.  Companies LOVE the idea of EMR’s because the required tech support, and database maintenance, and program upgrade requirements are virtual gold mines.  In the end though, it’s another of thousands of examples of business and enterprise making money on medicine – the real reason American medicine is falling apart.

Like the canary in the coal mine, as Family Medicine goes, so goes American health care.  If well-trained doctors are getting out of the business, the natural corollary is that you, over time, will be getting sicker (and poorer).

Family Medicine On The Move

Last night I spoke with the president-elect of the AAFP, Ted Epperly.  This is the guy who will shortly be running the show (as much as one person runs any national organization) at a time of dramatic change in American Medicine.

Epperly probably expends more energy in a day than I do in a week, so he’s perfect for his new job.  He mentioned that he is currently traveling close to 260 days a year.  Just the thought of being on the road that much makes me develop a nervous tic.  I often wish I could travel more…but not that much more.  I’d forget my own address.

Most of what I discussed with Epperly was with regard to running for an elected position at the AAFP.  There are numerous spots that need to be filled by family medicine residents and students every year; many of the elected spots go to attendees at the National Conference, where I’ve been for the past 5 days.  Epperly suggested that if anyone wants to lend a hand at the AAFP – student or resident – there will be a place for them.  The spot I was considering – as a delegate to the AAFP – would have required quite a bit of national travel and I needed my program director to support all the time away.  Turns out I didn’t apply for the spot and there appears to have been a good group of applicants this year to choose from anyway.  So, nothing lost by me not applying.

That said, according to Epperly anyway, I’m certainly not off the hook.  Nobody involved in family medicine is, irrespective of their involvement in the AAFP.  His premise is that American Health Care is poised for enormous changes over the next few years.  Both Obama and McCain will confront a care system that, for various complicated reason, is in shambles.  Idealogues both conservative and liberal (they like the term “progressive”) clearly see that reform of our system is imminent.  Exactly how that change occurrs, and who gets the lionshare of the “spoils” is going to be determined by how well each interested party lobbies the decision makers.  Thus, every believer in family medicine needs to be a part of the communication process.  Involvement in the AAFP is one way.  Letters to lawmakers is another.  Lobbying the AMA, letters to editors and blogging are big too (think, Kevin, M.D. etc.)

Without hesitation I say that family medicine doctors should be a major part of a health care system restructuring.  I think that family medicine – broadly-trained, general physicians – are without doubt the most effective and efficient agents in delivering health care.  I think they should have more power at the health care bargaining table than business, pharma, legal, governmental, insurance, para-professional groups, and allied health organizations that promote doctor-nurses, nurse practitioners, physician assistants, etc.

I’ve lived overseas and utilized a national health care system (Israel).  Additionally, I’ve read about the nationalized systems in New Zeland, Australia, UK, Canada, France, Germany and Japan.  While they all have their problems, one thing they have in common is an emphasis on primary care, and usually that care is provided by generalist doctors who have been trained in medical school and residency.  A recent article in the New York Times about eye-widening success in reforming health care in Siberia also describes how money was allocated almost exclusively toward primary care in individual villages.

Epperly was inspiring even because he is so confident that family medicine will prevail in this tussle for health care money.  His belief appears to be grounded in the idea that ultimately, family medicine is the best medicine not only for individuals, but also for health care systems.  Really, the only thing that appears to concern him is whether or not that message will be articulated effectively.  Epperly and some surrogates will be attending the Democratic National Convention this fall, and some other AAFP heavies will be similarly attending the Republican Convention.  The guy is on the road nearly every day in an effort to get the message out.  All who believe as he does, and as I do – that family medicine is the superior method of health care delivery – need to follow Epperly’s lead.  We may not travel the country 260 days a year, but we need to tell our stories that often.  If the world knows, healthcare wins.