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Old 12-18-2008, 09:32 AM   #21
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Originally Posted by burch64 View Post
When I lost my Dental Insurance I asked the Dentist about a discount for people who have no insurance and would be paying cash for their procedures.

He stated he would give a 10% discount for cash customers and gave me a sheet with his charges for different procedures.

Jim
Not to be argumentative, but I did some research on this by asking several dentists how of a discount they give to insurance companies. In most cases it 20-25%. Of course, the presumption is this will bring in more business.

Second, ask if you can visit the dentist without getting your teeth cleaned. A strong argument can be made that using proper dental cleaning with modern equipment that also stimulates the gums negates the need for dental cleaning at the dentist. I found it very difficult to find a dentist office that allows you to forego the routine cleaning - priced at $100.
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Old 12-18-2008, 10:14 AM   #22
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You can see from Rich in Tampa's post that he, as a doctor, is trained to keep me alive and will never vary from his Hippocratic oath. Plus, he is forced by our legal system to use "generally accepted medical practices" on me, regardless of my wishes. He cannot allow me to die, and as you can see from his post, he is virtually obligated to take control of my body, my lump, my life and my decisions to prevent me from dying..
Not quite my perception of the situation, Hobo. I and many colleagues like to support shared decision-making. This means to me that we might discuss each of the issues of concern to you, including the possibilities that I might have information that you don't have even after your research, and that I might have experience which you would find valuable in coming to your own decision. I would document that you chose to decline my advice and usually this would reduce my medicolegal risk. We do or omit stuff "against medical advice" all the time, upon the patient's direction.

It's true that there are exceptions to the above. For example, I would not do something which might harm my patient with no risk of benefit no matter what the patient asked for, it's my ethical obligation. And I might decide that a given patient was making an irrational choice due to some mental or physical condition that brings the soundness of their judgment into question.

I would probably not respond positively to a patient who comes in making vigorous demands that I do one thing or another -- that's not shared decision making, it's one-side decision making. It would be a whole different story if you thoughtfully told me what you wanted and why, I had a chance to respond and coach you, and ultimately we agreed on what was wise, or agreed to disagree. I would not jeopardize my medical license or malpractice protection to do so, but I routinely modify Plan A in order to meet special requests from patients. Both parties need to be comfortable with that decision, at least in my practice. I allow people to die of their disease routinely in my practice (in a referral cancer center), and in fact help keep them comfortable in the process.

Hope that clarifies what I meant.
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Old 12-18-2008, 10:35 AM   #23
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Gotta side with Rich on this one. I know how to do a lot of things. Surgery is not one of them. Neither is cancer prevention or diagnosis. When I take my car to a mechanic, I generally take his advice because I trust my mechanic. I had my house built and I hired a contractor to do the work. While we talked about the things I wanted in the house, he was responsible for building it and getting me the quality I required. I guess what I am trying to say is 'When you got to a specialist you should plan on taking his advice. If you go in not trusting his advice, don't go to him!"
This is a good point, but it simply doesn't apply to a doctor. He is obligated by a code of law that says he must follow the "legal standard of care". He may have seen 1000 non-cancerous lumps like he just cut out but he is required to have it tested for cancer.

Let me quote a journal article entitled:
Medical malpractice and the legal standard of care SpringerLink - Journal Article
"In this essay, I examine the relationship between lawsuits for medical malpractice and the legal standard of care. I suggest that there is an insidious, dynamic relationship between physicians' reactions to the recent increase in malpractice litigation and an artificial elevation of the legal standard of care.

The legal standard for proper medical care is based upon the community standard of care rather than the reasonable person standard. [When] that overtreatment or "defensive" medicine becomes widespread as a reaction to malpractice litigation, the legal standard becomes elevated as well.

Thus, it will increasingly be the case that unless a physician practices defensive medicine, and hence practices unreasonably, he/she risks being found liable for medical malpractice."

As a Registered Civil Engineer I was forced to follow by the same legal principles: "community standard of care". This is NOT like a contractor or a car mechanic who will give you his honest opinion. You cannot go elsewhere for a different opinion.

This is a professional who must live by the rules established by the law and lawyers - and it is driving up our health care costs.

Consider what happens when a bio-tech company comes out with a new, expensive piece of equipment to test for cancer. The bio-tech company salesman sells the unit to a laboratory and some rich man demands the best possible care. Soon that new piece of equipment becomes the new standard of care - and all doctors (and laboratories) must use it.

The old way of just looking at the lump under a microscope is no longer good enough. And now your laboratory bill just doubled.

The worst thing is human intelligence or the desire of the patient does not enter into the equation. You pay the doctor to be smart, but the law forces him to be a robot.

The American people need to get smart about health care. We need tort reform, or what I would call "NO FAULT MEDICAL CARE". That is, I can go into a doctor's office and sign an agreement to indemnify the doctor and hold him harmless. That means I cannot sue, but it also means my cost is cut in half. If my doctor makes a mistake - well, life ain't fair.
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Old 12-18-2008, 10:55 AM   #24
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Not quite my perception of the situation, Hobo. I and many colleagues like to support shared decision-making. This means to me that we might discuss each of the issues of concern to you, including the possibilities that I might have information that you don't have even after your research, and that I might have experience which you would find valuable in coming to your own decision. I would document that you chose to decline my advice and usually this would reduce my medicolegal risk. We do or omit stuff "against medical advice" all the time, upon the patient's direction.

It's true that there are exceptions to the above. For example, I would not do something which might harm my patient with no risk of benefit no matter what the patient asked for, it's my ethical obligation. And I might decide that a given patient was making an irrational choice due to some mental or physical condition that brings the soundness of their judgment into question.

I would probably not respond positively to a patient who comes in making vigorous demands that I do one thing or another -- that's not shared decision making, it's one-side decision making. It would be a whole different story if you thoughtfully told me what you wanted and why, I had a chance to respond and coach you, and ultimately we agreed on what was wise, or agreed to disagree. I would not jeopardize my medical license or malpractice protection to do so, but I routinely modify Plan A in order to meet special requests from patients. Both parties need to be comfortable with that decision, at least in my practice. I allow people to die of their disease routinely in my practice (in a referral cancer center), and in fact help keep them comfortable in the process.

Hope that clarifies what I meant.
That does clarify a lot. I hope we can agree that these kind of issues must be part of the upcoming debate on health care. I am sure that you would be much more comfortable with reasonable tort reform, as would I.

I have a great respect for most doctors - and their opinions. However, I have run into situations where the sword of Damocles, ie, malpractice law suits, hangs over the head of a doctor and has stood in the way of (what I consider) my God-given rights.

I also hope we can also agree that the trajectory of technology must be leveled off at some point. The way we are heading it will soon be possible to keep the human body alive indefinitely. An ethical sea change is clearly necessary. The Hippocratic oath needs to be modernized to reflect a world which is starting to feel the effects of over-population.
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Old 12-18-2008, 01:00 PM   #25
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My academic focus in my career has been decision analysis. I am painfully aware of the dangers of misinterpreting probabilities, and the need to incorporate patient values into medical decision making. Not all of my colleagues are so oriented, and not all of my patients are interested in it.

You might be surprised to know that perhaps 80% of my patients, when faced with that kind of decision, just say some form of, "I'll do whatever you recommend." Even then, I run through my patter in all its glory.

Sounds like you've been burned in the past. Just wanted to strike a cautionary note - this medicine gig can get pretty complex, pretty fast, with pretty serious results. For the easy stuff it probably doesn't matter whether you even see a doctor, but for the more serious issues we old folks will be facing sooner or later it's a good idea to have a shepherd in place.
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Old 12-18-2008, 01:29 PM   #26
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If you have a lump why even have it removed if you do not want it biopsied ? Why not just let it alone ? That way you will have charge over your body and not try to compromise a physician 's care . I can understand your feelings because I've spent years with patients like you ( I'm a retired RN) . They refuse I.V.'s that are for safety issues . They complain about everything . Most of the time they have fear and control issues and all they are doing is hurting themselves . Medical care is not an easy job . We work long hours and we regularly work through the night to help people not because of huge wages so give us the respect that we deserve . Question us , yes but do not demand .
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Old 12-19-2008, 08:52 AM   #27
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Hobo
If you have a lump why even have it removed if you do not want it biopsied ? Why not just let it alone ? That way you will have charge over your body and not try to compromise a physician 's care . I can understand your feelings because I've spent years with patients like you ( I'm a retired RN) . They refuse I.V.'s that are for safety issues . They complain about everything . Most of the time they have fear and control issues and all they are doing is hurting themselves . Medical care is not an easy job . We work long hours and we regularly work through the night to help people not because of huge wages so give us the respect that we deserve . Question us , yes but do not demand .
I mean no insult, but your karma just ran over my dogma. I have seen the hospital too many times and my philosophy on health care has developed after years of bad experiences - from paying high insurance premiums to being pushed into medical decisions that I regretted afterwards. I also have lived mostly in Indonesia for the past 10 years, so I have also seen a lot of instances of "alternative health care" - both good and bad.

You state:
If you have a lump why even have it removed if you do not want it biopsied? Why not just let it alone? That way you will have charge over your body and not try to compromise a physician 's care.
The answer to your questions are "because I choose to have the lump removed, and but do not choose to have it biopsied". As a medical professional you certainly have the right to ask, "Do you know the implications of not having a lump biopsied?"... but you do not have the right to question my personal decisions regarding my own body.

But, just so you understand my logic, I will tell you my rationale. First my family has a history of developing benign tumors, sometimes on my neck (where I shave), and sometimes on my hands or other places where they can become irritated.

Second, because of the high cost, I choose not to carry Part B Medicare insurance which covers doctor's visits. Plus, I do not want to pay the $100-$200 for a biopsy.

Third, if the tumor happens to be malignant, removing the tumor will solve the problem. If the tumor is thought to have metastasized, I would be in for a long series of tests and possible operations to cut out lymph nodes, etc. In addition, chemotherapy and radiation treatments would be required to hopefully cure the cancer.

At my age, I choose not to undergo the pain, suffering and expense of that procedure. The chances of the cancer re-occurring are good, and I know that death from some cause is somewhere on the horizon. With each passing year, the usual aches and pains of old age are beginning to appear. In short, my quality of life will (I hope) slowly deteriorate and eventually I will die from some cause.

I have seen too many older people suffer tremendously for many years before they finally die - I consider that absolutely inhumane medical treatment and refuse to go down that path. So if cancer is the way I am destine to die, then let the process begin. As I said previously, when I reach the point of no return, I will end of a slow, debilitating process of death by cancer with suicide.

Finally, let me say a few words about the rest of your post...

I am frankly amazed by your feelings that you have the right to dominate a patient. In your opinion, at what point does a patient give up his/her rights to choose what will happen to his body?

"They refuse I.V.'s that are for safety issues"
- Doesn't the patient have the right to accept or deny a procedure given for the patient's "safety"?

This is the attitude of medical professionals that bother me the most - "I will determine what is right and wrong, good or bad for you. I am a trained professional and you and your desires mean nothing. You are a mass of human protoplasm under my control." If this were an issue of precautionary measures to prevent a malpractice suit, I could understand. The country is in dire need of tort reform.

But, no, you have a real feeling of domination and complete disdain for patients who object. Plus, it sounds to me like the management of the place of your employment may be failing to properly schedule and hire the correct number of staff. No employee should be so overworked that he/she feels so overwhelmed and under appreciated that it reflects in the quality of work.

Once again I see some real fundamental flaws emerging in our existing health care system. I have seen them developing over the past few decades. The patients are not happy with the cost, and the health professionals are not happy with their working conditions. Before we allow the government to take over the system, I sincerely believe we need a health national debate on what is really wrong with our health care system.

I can honestly say the health care system in Indonesia is in far better condition than the system in the US. For one thing malpractice lawsuits are unheard of. For another, the country has a multi-tiered nursing program which cranks out a lot of nurses aids with 3 years training after high school. They take much of the workload of mundane tasks from the better-trained staff. Also, the technology is not as sophisticated so the staff seems to be under far less stress. Perhaps we should be looking more closely at how other countries deal with health care.
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Old 12-19-2008, 09:11 AM   #28
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..

I am frankly amazed by your feelings that you have the right to dominate a patient. In your opinion, at what point does a patient give up his/her rights to choose what will happen to his body?

"They refuse I.V.'s that are for safety issues" - Doesn't the patient have the right to accept or deny a procedure given for the patient's "safety"?

This is the attitude of medical professionals that bother me the most - "I will determine what is right and wrong, good or bad for you. I am a trained professional and you and your desires mean nothing. You are a mass of human protoplasm under my control." If this were an issue of precautionary measures to prevent a malpractice suit, I could understand. The country is in dire need of tort reform.

But, no, you have a real feeling of domination and complete disdain for patients who object..


You sir are wrong . When I was still working I was known for my ability to deal with difficult patients not by threatening by patience and understanding . I also believe all patients have the right to refuse treatment of any kind but I also will not place myself in an unsafe situation .
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Old 12-19-2008, 11:04 AM   #29
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I can understand your feelings because I've spent years with patients like you ( I'm a retired RN) . They refuse I.V.'s that are for safety issues . They complain about everything . Most of the time they have fear and control issues and all they are doing is hurting themselves . Medical care is not an easy job . We work long hours and we regularly work through the night to help people not because of huge wages so give us the respect that we deserve .
Sorry, but that doesn't sound like "patience and understanding" to me.
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Old 12-19-2008, 12:30 PM   #30
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This is certainly an important topic and an interesting discussion, but I would ask that everyone take a deep breath and calm down before posting further.
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Old 12-19-2008, 06:10 PM   #31
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Thrilled to take cash - yes. A discount to the same rate they charge insurance companies? I have never seen it readily offered.
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This is certainly an important topic and an interesting discussion, but I would ask that everyone take a deep breath and calm down before posting further.
Well, arguing with me isn't going to get you any closer to finding a doctor or dentist who's willing to offer a discount. They're out there, I've found them on Oahu, and I bet you can find them too.

But, hey, if you just want an argument then [insert Monty Python quote here]. I'm not sure how that'll solve your healthcare problems, and probably not as well as my suggested solution, but maybe yours will make you feel better. Good luck with that. Either way you'll have to do it without my further assistance-- I'm out of this thread.
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