Return to Capitalism

by William Northwall

  When you go in for a CAT scan today, you see a computer that looks like a laptop and a small circular device with a movable table that goes through the center. My machine weighed 43,000 pounds, needed special government approval to travel from Cleveland, Ohio to Kearney, Nebraska on Interstate 80, and when it arrived, we had to hire house movers to bring in their large equipment to move it from the truck to a 20 by 20 foot room that we had built for it. Off the local utilities line, we brought in 480volt three-phase electric power and the cables carrying this power were from another room and about 3 inches in diameter. When a farmer on the same circuit turned on his 200-horsepower grain dryer, the current dropped on our lines and the photomultiplier tubes behind our x-ray detectors, designed to shut off the x-ray beam at lower power, overdrove our x-ray tubes to the point of destruction. Our CAT scanner x-ray tubes were $25,000 apiece and we didn’t wish to burn them up like light bulbs. So, our utility then ran our incoming power line around multiple blocks until they could document smoothing out of the current. Next to the examining room, we built an 8 by 10foot control room shielded by a leaded window. Next to that room, we had an 8 by 10foot computer room. The computer had to be cooled down to 68 degrees by 4 tons of air-conditioning or else the transistors in the computer would fry.

  After two years, the advances in CT technology made my machine obsolete. My hospital, realizing they’d made a mistake, told me they were buying me out for 20 cents on the dollar. I told them they had to sweeten their offer or else I’d direct my referring doctors to send their patients 50 miles to the next CT facility to the east. They finally relented. Next thing, about 20 Chinese men and women showed up and spent about two weeks at my hospital. Their interpreter was a Los Angeles radiologist who’d accompanied them. He saidbeforethey left, they would be able to completely re-manufacture any component that failed. I got a kick out of watching these guys in the hospital cafeteria. The first day they all took chicken noodle soup, then puzzled over how to open their crackers wrapped in cellophane. I was really happy to think that after all the work I went through to get this machine, that it wouldn’t just end up in the scrap yard.

  Today, for a Medicare patient, the total allowable, or global charge is $194.52. Of this, the technical or hospital component is $129.20 and the radiologist for supervision and interpretation gets $65.32. With Medicare paying 80% of this or $52.26 the radiologist can get the remaining 20% from either the patient’s supplemental insurance, or from his out-of-pocket payment. These numbers are from the successor to my old practice in Nebraska, where about 40% of the patients are in Medicare. For private paying patients, this office tries to collect 200-230% of the Medicare allowable or about $130.64-$150.24. Stated another way, $1,000 in 1980 is worth $3,142.98 in 2017 dollars. The decline from $3,143 to $65.32 is a decline of 97.9%! Medicare’s effect on doctors’ reimbursements: abysmal.

  Not only did I have to cover half a million of debt, prescribe the exam, and interpret it, but I was also in charge of everything, including billing the patient and paying all the bills. I write about all this today not to get a pat on the back, but to try to explain what a big deal this all was back in 1980. I really was not only an enterprising entrepreneur, but very much a pioneer. I saw a lot in my years in medicine, and learned a lot. So, when I talk about healthcare, consider that I might know a thing or two on the subject.

  Malpractice – The other day, a nurse asked me why I retired early and my stock answer was that I was worn out from all-night calls and then had to work hard the following day after being up for several hours during the night. But seriously, I went through about a half-dozen lawsuits and these were devastating to me; most being in my view, totally ridiculous. I’ll give you the basic facts of two cases.

  The first involved a local drug dealer attending a beer party, who ran out of beer, hopped on his motorcycle, and on the way to the liquor store, ran head-first into a brick wall. The emergency crew phoned ahead and the hospital staff doctor on-call that night refused to come in. Then the hospital called me and I came in to CAT scan this unfortunate guy’s head. Watching the chopper descend, I told myself that this wasn’t going to end well. We moved the patient carefully onto the CT table, got a cross-table x-ray of the cervical spine to rule out a fracture, which was negative, but still kept his neck splinted to be cautious. CT showed massive brain injury. The patient was in Cheyne-Stokes respiration, which meant a near-death state of affairs. We got this guy transferred out of the department and I went home. The next morning, someone on the nursing floor un-splinted the guy’s neck, another internist entered the room, and the patient’s condition worsened. Another cross-table neck x-ray now showed the cervical spine pulled apart and offset at one level and the internist ran out of the room, screaming that the radiologist had missed a c-spine fracture. The patient made a fairly surprising recovery, but was left with a Brown-Sequard Syndrome, where he laughed when he wanted to cry and cried when he wanted to laugh. The patient sued me for missing a cervical spine fracture, but there was no fracture. The force of running into a brick wall was so severe that the energy ripped apart the ligaments that hold the cervical spine bone elements together and ligaments do not show up on x-ray. Nevertheless, my defense lawyer didn’t want to bring a guy dragging one leg before a jury, so he and the insurance company decided to settle. The settlement was nearly a million dollars.

  I called another case the “missing-rib case.” A 30-year-old guy saw his doctor for rib pain. My department did a nuclear bone scan of the skeleton and, low and behold, there was one “hot spot” on one rib which matched his pain. My partner was showing this to the attending physician while I walked past the room exclaiming, “rib fracture.” The attending doctor got irate and said the patient denied any history of trauma; therefore, it had to be a metastatic cancer deposit and needed to be worked up. That afternoon, I was called into the nuclear department to “localize” the hot spot, which I did, and then marked the overlying skin with a magic marker for a biopsy guide to be done later. Several days later, the first x-ray of a rib bone section, about 2 inches long, showed no fracture. The orthopedic surgeon then went back to the O.R. and biopsied an adjacent rib, and this specimen showed a simple and traumatic bone fracture; no cancer. Several months later, I received notice that I was being sued for missing a rib fracture. Our investigation showed the following: this guy was a drug dealer and the highway patrol had entered his house and beat him up. After I marked his rib, he was given permission to go home for the weekend, where he showered and then had his wife re-mark the rib that I’d marked. When he got to the operating room, the surgeon was late and didn’t get to push on the sore spot to positively identify the area, as the patient was then asleep. So, who did he sue? Me, and the final insult was when later my insurance company told me I’d had so many lawsuits that they were dropping me, forcing me to go to another company.

  So, when you hear the trial attorneys speak about what they do, telling the public that they’re just like the cops giving out tickets to red light runners who were never bad peoplebut just made a mistake, and they were there to “protect” the public, don’t believe them! They are there to enrich themselves (one in Florida is rumored to make $60 million a year). Our Congressmen and Senators are lawyers also, so don’t expect them to do much about this scourge working against society.

  No doctor wants to injure anyone; they studied toward their training to help people, not to injure them. Medical errors are screw-ups of which many could be eliminated with bar and color-coding, standardizing medicine on the emergency tray, and the like. Today, the plaintiff’s complaint is frequently read over the radio to the public, and the doctor is humiliated and hides away, often even shunned by his colleagues, while an attempt is made to keep everything secret. Wrong. Everything needs to be out in the open and analyzed as an engineering matter to be assured that the screw-up doesn’t recur. Too many now think in terms of winning the lottery and are urged on by greedy trial lawyers. Advocate for your Congressman to put an end to
this tragedy that so contributes to the high cost of healthcare.

  Why was I singled out for these lawsuits? I was the “deep pockets”, which was a high-income doctor that trial attorneys always sought out.

  Do Radiologists Add Value to Medicine? When I entered practice in Nebraska, my town of Kearney had 30 doctors, almost all had their own x-ray machine, and they all “read” their own exams. They would say that when they had a question, they would take their office films over to the radiologist for his opinion. Well, here is how it went too many times, exemplified by this event. A kindly old GP brought in a chest x-ray of one of his patient’s, saying that he was concerned about the appearance of something in the upper left lung. I took one look and said that didn’t bother me, but the inch sized mass in the lower right lung did need attention. It wasn’t two weeks later that the same GP then brought over another exam, saying he was concerned about the appearance of the lower right lung and I said again, “that didn’t bother me, but the inch in diameter mass in the upper left lung certainly did need attention.”

  What do radiologists do? My wife was asked once in the early years if I also worked on televisions. First thing is to get the most optimum film image possible. The patient has to be positioned well and close to the film or electronic detector capturing the image. Blurring from motion has to be diminished with respiration suspended and exposure time has to be very rapid. The energy applied to the x-ray tube has to be optimum. For use of any iodine-containing contrast media, the voltage sent to the x-ray tube should be about 70,000 volts, from which the resulting x-rays are most profoundly absorbed when near the K-edge of iodine (a physical phenomenon). On the other hand, if air in the lungs is to be emphasized, then energy around 120,000 volts is more optimum. We used very fine focal points on the tungsten target in the x-ray tube to reduce the “penumbra” effect and shaped the beam down to just the smallest size possible, with collimators to reduce “scatter”. To further clean up the image, we often put a grid of very fine, closely spaced lead strips in front of the film holder.

  The next thing was to “read” the study and render an opinion to the ordering physician. Much studying followed by experience made it possible to separate normal anatomy from variants of normal, and then to recognize the pathologic. Finally, we had to give a “differential diagnosis” of all the possible things to explain the x-ray “puzzle.” We looked at it as a game, in a way, and enjoyed being in the center of the action between the arguing surgeon and his colleague, the internal medicine doctor. We took a lot of pride in our work. When I started in 1972, there were 112 of us and we all knew each other, were friends, and frequently consulted one another. My forte was nuclear physics and I loved seeing the advent of MRI and would question my physicists on how it worked; in a way, it’s still a mystery.

  Medicine has made unbelievable advances in my lifetime and I loved being part of it. But I have to say that it is now very disheartening to experience politicians taking over healthcare. Doctors today are depressed with lawsuit hazards, bureaucratic regulations, and forever decreasing reimbursement; the “rewards” of many years of training facing unbelievable stresses, poor public esteem, and high taxes. And yet, the many doctors I’m now seeing in St. Petersburg, Florida, in spite of all the problems, are simply marvelous.

  Here is how I entered medicine. My first night of working the ER on-call physician, there were two head-on auto collisions inFalls City and Beemer, Nebraska. There were 4in each vehicle or 16 people. Half died on the scene, and 8 came in by ambulance. I had only a student nurse to help me and initially, no staff doctor could be awakened to help me. Half died in front of me, as I was putting tubes in all orifices and ordering blood for all. Over the years, our department went through too many cardiac arrests to count, usually anaphylaxis from the x-ray contrast media in use at the time. I later designed my department to be back-to-back with the ER and the ER became staffed with full-time ER doctors. We installed emergency cords to pull alarms in all exam rooms, prompting a whole team to immediately enter from the ER and take over. These paramedical people were terrific. One would pump the heart, another would install an endotracheal tube to breathe the patient, while another started an I.V. and administered appropriate medicine. All this while another kept a record of all going on. Terrific!

  The worst part of medicine to me was all of the teenagers killing themselves in their cars. In my final year, I was on-call for 5 days over Christmas. In that time, we had 19 trauma codes and there were multiple people injured, requiring a team effort. One night, our ER was filled and we had a deceased mother in one room, with her 16-year-old daughter in the next room crying for her. In another room was a father, asking how his 16-year-old son was doing in the next room, who was already dead. I hated lying at home in bed too many nights hearing the wamp, wamp, wamp of the hospital helicopter coming in, knowing that in 20 minutes, I’d have to be at the hospital. In those days, it took 45 minutes to transfer a set of CT images over the telephone wire, so it was just easier to go in and supervise. After this awful Christmas, I looked at my bank account and said to myself, “never again, I’m getting out of here.” I retired the following summer at age 57. Medicine was exciting and it was much fun building a practice, but after nearly 30 years, I was worn out and had too many other things to do in life.

  I do owe many thanks to so many who nurtured me, taught me, and guided me. I’ll recognize just a few here. There was Dr. Day, head of pre-med at Westminster College of Fulton, Missouri. He spent hours preparing us for med school and what to expect when we got into practice. He always compared us to his most famous student, Dr. Starzl, who figured out how to do the first transplant. My radiology chief was Dr. Hunt, who could be a real terror. He came to the med school in Omaha in 1932 and was given charge of the intern program for a salary when most physicians soon had to earn a living planting trees on Dodge street, the main route into Omaha, as most all economic activity had shut down because of the Great Depression. My next chief was Bill Wilson, who studied under Keats at the University of Virginia, went on for post-radiology training at the University of Minnesota under Junkins, and together they figured out how to do the first coronary arteriogram. They not only learned how to shape the first catheters, they also had to design all the x-ray equipment. Roone Arlidge at ABC had just come up with TV recording on a disc so the network could create “instant replay.” Wilson added this recording technology to his cath lab. Then, Hunt hired Wilson to be his replacement for department chief, and Wilson recreated this cath lab at the Nebraska Medical Center. When I studied under him he had the second largest collection of coronary arteriograms: 350. There have been many more to whom I am so indebted. To Rosemary, my first wife, thank you. To my parents, Gertrude and Virgil Northwall, you made everything possible. I led a blessed life because of so many wonderful people.

  I sincerely hope that you take my book with interest and think about things we doctors face, not only in medicine, but under the general economic conditions that most all of us live in. Please go to my website and offer me comments of any flavor to help continue the debate and advocate for change.

  Please address comments to Dr. Northwall by going to the following: https://williamnorthwall.comAll comments are welcome, from critical to favorable. If you wish to join a movement to solicit politicians to advocate for the agenda and ideas offered in this book, please register by including your e-mail address.

  CHART TO RANK CANDIDATES

  Utilize the chart on the following page to rank your political candidates. In each row, a candidate will receive a Y for yes if they meet the requirements for the item, an N for no if they do not, or a U if it is still unknown. Each yes earns the candidate 10%, and the total amount should represent a percentage of how capitalistic the candidate is. For instance, if a candidate earns four yeses, they are 40% capitalistic. Below are the factors you will be using for evaluation.

  Favor a low flat tax (e.g. 7%) applied to everyone with no exemptions or deductions.

&nbs
p; Favor sound money tied to either the value of gold or a basket of commodities.