For anyone who has ever had a "Doctor" show up on scene

[Too Old To Work]

Of course the difference between a physician and a paramedic is a non-anesthesia or EM physician knows their boundaries and most likely look for another method whereas a paramedic would attempt even if a proper analysis would dictate more prudent measures. There's a reason that paramedics get hammered in intubation studies and primary care physicians don't, despite intubation being in the legal scope of practice of both.

While primary care physicians might be able to intubate, how often do you think that they run into situations where they have to intubate? My guess is not very often at all. I'll have to ask my PCP when he last intubated next time I see him. My guess is that the answer will be "During residency", which in his case was 15 or 20 years ago.

If you look at the intubation studies, you'll see that it's not situations where the paramedics shouldn't have intubated, it's paramedics that have fewer opportunities to intubate for any number of reasons.

 

[JPINFV]

I fully agree that very few medical specialties are normally in situations that require intubation. However I'll argue that even in situations that would necessitate intubation, physicians outside of those specialties are still not going to intubate because they know that they're out of practice.

Now the question is, if paramedics in some systems are not getting the opportunities to intubate to maintain proficiency, should they be placing ET tubes to begin with instead of finding another way?

 

[Too Old To Work]

I fully agree that very few medical specialties are normally in situations that require intubation. However I'll argue that even in situations that would necessitate intubation, physicians outside of those specialties are still not going to intubate because they know that they're out of practice.

I agree with you. I don't agree that any doctor is more qualified than any paramedic at the scene of an emergency. (I don't think it was you that said that) In 30+ years of EMS in a city with three medical schools, and more than one trauma center, I've had doctors show up on scene any number of times. Well, at least they claimed to be doctors, but not one ever produced a license or other proof. Nor did any of them offer to accompany the patient to the hospital as our protocol requires. Not to mention sign off on the PCR. Not to mention the ones that were at social events and probably had alcohol on board. That's a different story.

It doesn't seem to happen much anymore, but the day shift probably does see it more than I do.

Now the question is, if paramedics in some systems are not getting the opportunities to intubate to maintain proficiency, should they be placing ET tubes to begin with instead of finding another way?

Rust out is a severe problem in EMS systems that have too many medics and not enough skills. The intubation issues seem to be more severe in all ALS systems as opposed to tiered systems. The Gauche study from LA County a few years ago showed that some of the medics hadn't intubated in over three years. OTOH, in my system we have a much lower paramedic to patient ratio and a dozen or so tubes a year per medic are the norm.

Exposure to a larger number of patients seems to make a difference in success rates for intubation.

I think you raise a valid point and I think some systems with a low number of intubations per paramedice might start looking at alternatives to intubation. Other systems won't have to. The bigger problem is that EMS regulators, at least in many areas, take an "one sized fits all" approach to regulation and scope of practice.

Personally, I'd reduce the number of paramedics in most systems. That's probably a topic for another thread.

 

[firetender]

Personally, I'd reduce the number of paramedics in most systems. That's probably a topic for another thread.

Please, do!

 

[Too Old To Work]

Please, do!

I see someone else has started a thread. I think I'll lurk for a while.

 

[Veneficus]

This is funny...

I find it kind of sad actually. They are nearer to finishing than we are, and not only do they not seem to know what is in their textbooks, they have almost no clinical skills to speak of at all.

In my observation they spend hours practcing how to tie suture knots with pieces of string, but cannot suture.

A few weeks ago during a code I had a 4th year tell me he didn't know CPR.

He didn't know when he was looking at a common anatomical variation on a patient. (right out of the textbook)

I met another who I taught how to staple wounds. Yet another who never started an IV.

These are students in a really well known and "prestigious" school.

If this is "the best there is" I sure do feel sorry for a patient who gets the mediocre. I am starting to think the reason that the US medical system discriminates against foreign doctors is because it is painfully obvious how badly the students here are trained when standing next to one. Perhaps they are expert at passing a standardized test, but the ones I saw can't do anything else.

I know I don't go to the most prestigious school ever, but I can say with certainty that nobody in my class would have made it out of the 1st year if they couldn't start an IV, perform cpr, draw blood, staple a wound, or perform a physical exam and interview a patient.

In the second year we have a semester long class (one of our 7 per semester) that teaches you how to function with emergency patients both in and out of the hospital. All of the skills covered in a US paramedic class in addition to much of the bookwork is covered. You don't get to the next year if you fail a class.

Stealing a quote from one of my mentors:

"There are many people with medical degrees, but most will never be a "doctor."

Think about it, in July, these 4th year US students will be interns. A bit scary I think.

 

[Too Old To Work]

I find it kind of sad actually. They are nearer to finishing than we are, and not only do they not seem to know what is in their textbooks, they have almost no clinical skills to speak of at all.

In my observation they spend hours practcing how to tie suture knots with pieces of string, but cannot suture.

I'm don't know what country you were trained in, so I can't comment. However, I do know that we just had a "doctor" trained in another country fail our EMT training program. Apparently she was averse to actually touching patients. Anecdotal though it is, that's my experience. Not to mention the graduates of foreign medical schools I see in residency here. I'm not impressed.

If our medical care is so bad, why is it that patients come here from all over the world to seek treatment? Hmmm...

 

[Veneficus]

I'm don't know what country you were trained in, so I can't comment. However, I do know that we just had a "doctor" trained in another country fail our EMT training program....

I am sure I would fail an EMT program. Probably for many reasons. Not least of which is I would have to forget everything I knew in order regurgitate treatment modalities that are clinically suspect or outright disproven.

Apparently she was averse to actually touching patients.

Is that a problem with the training or a problem with the provider? Sounds to me like both.

Anecdotal though it is, that's my experience. Not to mention the graduates of foreign medical schools I see in residency here. I'm not impressed.

I would be very interested to know where you were at and where these students came from. I won't deny that there are school around the world, from South America to europe to Asia, where you can buy a degree without ever actually attending class or something in between great education and a bribe. But there are many countries particularly on my side of the pond who have been training physicians before the United States was founded and have quite respectable traditions and put out proficent providers on a regular basis.

You of course know there is an informal list of facilities that many foreign graduates consult to find places that will accept them based soley on their USMLE score?

I wager I can teach anyone to take a standardized test in less than 8 months and do well.

There are also some facilities that will take foreign grads because a benefit of being a FMG is you don't have to go throgh match and can negotiate your salary requirements. There is no shortage of people who will spend a few years supported by family working like a slave for next to nothing in order to get a spot. There are also some rather infamous facilities (particularly in NYC. I am too kind to name them publically) that specifically look to take advantage of that.

If our medical care is so bad, why is it that patients come here from all over the world to seek treatment? Hmmm...

I always love this question because it is so short sighted. But let me offer you:

Medical tourism is a booming business, it is not uncommon for people to leave the US in order to have treatments or procedures done that are unaffordable or even inaccessable. from Euthanasia, to various cancer treatments, plastic surgery, gender reassignment, and a host of others. Some hospitals overseas are even getting Joint commision accredidation so US insurance companies will pay to transport and have treatment performed at a much less cost than in the US.

Because in the US anyone with the money can have any treatment performed, if you have the means it is quite logical to go to someplace that has regular experience at performing treatments that are very expensive over going to a place that has capable people who have never done it before or do it so infrequently that the outcomes are often poor.

You also have to look at where they go and what they are coming from. It is much easier for somebody from Mexico to come to the US for care than to go to England. At the same time, outside of North and South America, the rest of the world is closer to somewhere else. (Like Sweden)

Often the aristocratic people are not going to the US to have treatment in any podunk hospital, they are going to specific facilities for highly specialized treatments and physician quality that can be found nowhere else. But those quality physicians are not always from the US. Because of the money available here to pay quality people, it attracts quality people. I encourage you to look up who performed highly comlex or experimental procedures and where they were trained. I think you will be surprised.

I have spent time in a handful of countries, and I have seen people show up in the A&E departments of a British hospital, drop a stack of their medical records on the desk say "I have cancer help me." I even saw one guy at customs at the airport tell the agent he was in Britian soley to seek medical treatment and get let in.

I am from the US and I can tell you if some guy stopped in the airport told them you had nothing and were seeking medical treatment, you probably would get turned away. If you actually made it in, you certainly would not show up in the ED drop your record on the desk at the Mayo Clinic and expect the most advanced lifesaving medicine available that money could buy, nor the best physician in the country to put his paying customers on hold to take your case on charity. (not saying she wouldn't but I wouldn't bet on it)

Not just everyday people, but even some celebrities with almost limitless spending power go outside the US for medical care.

Perhaps you could address if US medicine is so great why US citizens are going to Canada for things as mundane as prescription medicine?

Medicine is not simply a procedure performed in a spa or factory, it is a totally encompassing event for people. The average American certainly doesn't have access to the private dieticians, physical therapists, home health physicians, etc. that the worlds wealthy purchase when they come here.

Also take a look at the outcome to cost ratio of US medicine. The US spends way more and gets way less.

recently I was at a facility where a patient was seen by a surgeon, an intensivist, a hospitalist, a nephrologist, and an infectious disease specialist. They were all making recommendations and some of the directives actually conflicted. The nurse dutifully carried them all out in the order they were given. When I asked who was coordinating all of this, everyone just looked at me like I was crazy. The answer: "that is how we do it here." My next question: "Do all of you guys bill for this?" The answer: Of course! Lets not forget the wound care NP, the dietician, and the pain control PA.

So a patient with cellulitis and new onset renal failure was seen and billed by 5 doctors whos total plan was: 2 a day dressing changes with xeroform, IV vanc. standard dialysis protocol, protocol diet for heart failure, renal failure, and diabetis. (basically chicken and rice every meal 2000 calories per day) IV dilauded 2 mg, 8 hours, discontinue fentynal patch, and percocet every 6 hours. Schedule for fistula.

The best medicine their is didn't know fent. is excreted by the fecal route so you don't have to worry about building toxic levels like in dilauded and percocet. The PA was starting the pain protocol from the begining seemingly oblivious to the fact the intensivist wrote for dilauded. (which is not only compounding the opioid levels in the blood but is removed by dialysis so when the patient is dialyzed next AM they she might go 2-8 hours before any pain control is given)

You call that the best?

 

[JPINFV]

The Doctor can come along anytime, provided that Ms. Pond rides up front.


/not entirely sure how obscure this will be for this board...

 

[MrBrown]

I find medicine a funny subject. The age old notion of doctor as healer has long been raped and pilfered by the medicopharmaceutical establishment and if Western nations have the best healthcare in the world how come we are amongst the sickest in the world?

I don't see hill people in China dying of heart attacks and stroke and the Type II diabetes on the insulin and ACE inhibitors for hypertension and being scheduled for cardiac bypass surgery which has no real evidence it even works by the way but sssssh don't tell the AMA, the Cardiologists or the drug companies.

New Zealand has overtaken the US as the nation with the largest percentage of overweight and dangeriously or mortubound obese people in the world. Our public healthcare system is struggling to cope and waiting lists for elective procedures are getting longer, some specialties are not accepting referrals and I joked with my doctor that it's a case of "hurry up and die so we can give your place to somebody else", his answer? You're spot on mate, do you want my job?

Now this is only observational (the best kind of evidence there is according to Scientific Research 101 ... not) but I find the few American physicians that I know are (and treading carefully here) ... very cocky in thier perception of righteousness and somewhat cultured to believe that the letters MD after thier name mean Mircale Dealer.

Oh and I must ask, if the most important thing to most Paramedic (ALS) students I see on these forums is a standardised test that I have seen foreign trained non "American style" ALS Ambulance Officers and Paramedics pass and comment how ridiciously, indeed criminally, inadequate and easy it was .... why should we expect anything different from the USMLE?

Oh and I probably dont have to find out anyway, as a FMG with his MBChB Brown only has to take USMLE Step 3.

 

[Too Old To Work]

I am sure I would fail an EMT program. Probably for many reasons. Not least of which is I would have to forget everything I knew in order regurgitate treatment modalities that are clinically suspect or outright disproven.

Or maybe you're just not that smart.

Is that a problem with the training or a problem with the provider? Sounds to me like both.

If the other EMTs in her class can pass with the same training regimen, presumably she could have.

Because in the US anyone with the money can have any treatment performed, if you have the means it is quite logical to go to someplace that has regular experience at performing treatments that are very expensive over going to a place that has capable people who have never done it before or do it so infrequently that the outcomes are often poor.

Sounds like a terrible idea. Use your money or insurance to pick the provider with the most experience. Who could ever think that would work.

You also have to look at where they go and what they are coming from. It is much easier for somebody from Mexico to come to the US for care than to go to England. At the same time, outside of North and South America, the rest of the world is closer to somewhere else. (Like Sweden)

Really? Last time I looked, Saudi Arabia was not that close to America. Yet, a number of members of the Royal Saud family come to the US for treatment on regular basis.

Often the aristocratic people are not going to the US to have treatment in any podunk hospital, they are going to specific facilities for highly specialized treatments and physician quality that can be found nowhere else. But those quality physicians are not always from the US. Because of the money available here to pay quality people, it attracts quality people. I encourage you to look up who performed highly comlex or experimental procedures and where they were trained. I think you will be surprised.

I'd guess most of them were trained here, but I might be wrong.

I have spent time in a handful of countries, and I have seen people show up in the A&E departments of a British hospital, drop a stack of their medical records on the desk say "I have cancer help me." I even saw one guy at customs at the airport tell the agent he was in Britian soley to seek medical treatment and get let in.

All those stories I read about rationing in the UK, long waits for routine procedures, people being left to die in wards because there aren't enough nurses, must be made up to scare us silly Americans.

I am from the US and I can tell you if some guy stopped in the airport told them you had nothing and were seeking medical treatment, you probably would get turned away. If you actually made it in, you certainly would not show up in the ED drop your record on the desk at the Mayo Clinic and expect the most advanced lifesaving medicine available that money could buy, nor the best physician in the country to put his paying customers on hold to take your case on charity. (not saying she wouldn't but I wouldn't bet on it)

It would probably depend on a number of factors. You've made up an interesting scenario. I certainly know that if someone shows up at an Emergency Department and requests care they will not be turned away. There's a specific law about that.

Perhaps you could address if US medicine is so great why US citizens are going to Canada for things as mundane as prescription medicine?

I don't know that they are, but I do know that even Canadian politicians come to the US for care they can't get in their own country. I have a friend who's wife is Canadian. Her mother died from breast cancer because it took six months to get the needed diagnostic tests. By then it was too late. I know that Canadian routinely have to wait for month to get procedures that take days or weeks to get scheduled in the US. I know that California has more CT machines than Canada. Oh, and I know that Canada is now going to start letting it's subjects pay doctors to supplement the government run health services. Oh, and politicians in Canada are calling for it to adopt more US style health care.

Medicine is not simply a procedure performed in a spa or factory, it is a totally encompassing event for people. The average American certainly doesn't have access to the private dieticians, physical therapists, home health physicians, etc. that the worlds wealthy purchase when they come here.

Also take a look at the outcome to cost ratio of US medicine. The US spends way more and gets way less.

recently I was at a facility where a patient was seen by a surgeon, an intensivist, a hospitalist, a nephrologist, and an infectious disease specialist. They were all making recommendations and some of the directives actually conflicted. The nurse dutifully carried them all out in the order they were given. When I asked who was coordinating all of this, everyone just looked at me like I was crazy. The answer: "that is how we do it here." My next question: "Do all of you guys bill for this?" The answer: Of course! Lets not forget the wound care NP, the dietician, and the pain control PA.

So a patient with cellulitis and new onset renal failure was seen and billed by 5 doctors whos total plan was: 2 a day dressing changes with xeroform, IV vanc. standard dialysis protocol, protocol diet for heart failure, renal failure, and diabetis. (basically chicken and rice every meal 2000 calories per day) IV dilauded 2 mg, 8 hours, discontinue fentynal patch, and percocet every 6 hours. Schedule for fistula.

The best medicine their is didn't know fent. is excreted by the fecal route so you don't have to worry about building toxic levels like in dilauded and percocet. The PA was starting the pain protocol from the begining seemingly oblivious to the fact the intensivist wrote for dilauded. (which is not only compounding the opioid levels in the blood but is removed by dialysis so when the patient is dialyzed next AM they she might go 2-8 hours before any pain control is given)

You call that the best?

It's better than just telling them to go home and die, which seems to be the norm in much of the world. Or letting them die in a heat wave because all of the nursing home staff is on vacation. As happened in France a few years back.

I'm also surprised that you knew so much about a patient that you weren't involved in treating.

 

[Veneficus]

Oh and I probably dont have to find out anyway, as a FMG with his MBChB Brown only has to take USMLE Step 3.

Check that out closer to graduation.

Most states will not hire you unless you have a US residency. Nobody Anyone I know ever heard of can get malpractice insurance in the US. without a US residency. I even know a doctor who was a surgeon for 13 years in Europe who just took Step I and both parts of the step II to attempt to get a surgical residency to transfer here.

The politics of US medicine are quite involved. But like I said, it really makes me wonder what really makes them think they are the best.

 

[jjesusfreak01]

Check that out closer to graduation.

Most states will not hire you unless you have a US residency. Nobody Anyone I know ever heard of can get malpractice insurance in the US. without a US residency. I even know a doctor who was a surgeon for 13 years in Europe who just took Step I and both parts of the step II to attempt to get a surgical residency to transfer here.

The politics of US medicine are quite involved. But like I said, it really makes me wonder what really makes them think they are the best.

I would think it has a lot to do with the fact that US residencies rely on a very specific system of training, and residencies are also accredited by the ACGME, so imagine the situation that you get into when you try to get into EMS in another country (proving that you have the required training and then taking classes to fill the gaps) and then multiply that by 100.

 

[Veneficus]

Or maybe you're just not that smart.

That could very well be. Who knows?

If the other EMTs in her class can pass with the same training regimen, presumably she could have.

Your logic is she had the opportunity to "unlearn" the medicine she learned in medical school in order to fulfil the mindless EMT-Basic requirements? Perhaps she forgot to consult med control before giving nitro or some other medication people take at home without the aid of an EMT?

Maybe she knew that "pink frothy sputum" was a histological finding and didn't think it was the answer she was supposed to pick because the scenario didn't state "on your morning sputum test you find..." (I am sure you know that sputum tests are best done in the morning.)

Really? Last time I looked, Saudi Arabia was not that close to America. Yet, a number of members of the Royal Saud family come to the US for treatment on regular basis.

Is this a ventmedic alias?

I think you totally missed the point and are trying to argue something stupid.

My statement was that wealthy people will pick the most experienced place to buy their care and that other people who are less wealthy choose to go somewhere closer to home?

Because the Saudi royal family does it, it must be the best right? Maybe you might consider some of the other things they do too.
(pathetic)

All those stories I read about rationing in the UK, long waits for routine procedures, people being left to die in wards becauseAmericans. there aren't enough nurses, must be made up to scare us silly

Don't know where you read your stories, but I have been there and not only did I not see anything remotely like that, but most of the people I asked about it laughed at the prospect. Have you been there?

It would probably depend on a number of factors. You've made up an interesting scenario. I certainly know that if someone shows up at an Emergency Department and requests care they will not be turned away. There's a specific law about that.

As I understand the law, they cannot be turned away for stabilizing care, that does not include longterm health care, or surgery that returns them to previous function. I am sure there are more than a few hospitals that would provide it, but I am also sure there are atleast equal a number that won't do anything more than they absolutely have to.

I don't know that they are, but I do know that even Canadian politicians come to the US for care they can't get in their own country.

Can't get for what reason? Because it costs a lot and there is no demonstrated benefit?

Why don't you compare the cost of peritoneal dialysis to the cost of hemodialysis and then look at the outcomes?

Because they were ruled out for some reason?

In the US an alcoholic can pay for a liver transplant. Some former pro baseball player did a few years ago. In most countries I know of, being an alcoholic (aka drug abuser) disqualifies you from a transplant list. Truly medicine to be proud of I guess.

I doubt any of us are privy to the actual reasons such care was not available. Including the prospect that something might be made public that shouldn't be.

I have a friend who's wife is Canadian. Her mother died from breast cancer because it took six months to get the needed diagnostic tests. By then it was too late.

Too late for what? If there was already cancer would the diagnostic have made a difference based on the type of neoplasm? Please if you are going to argue this, I would love to hear the details, otherwise it is just hearsay.

If I may tell you somethign about neoplasms. Some develop rather aggresively, the treatment options are limited and the prognosis often poor. Some develop over years and if a diagnostic test (and I would be very interested to know exactly which one) that took 6 months to get determined life or death, I would seriously worry about their pathology departments.

I know that Canadian routinely have to wait for month to get procedures that take days or weeks to get scheduled in the US. I know that California has more CT machines than Canada..

Because Americans can't diagnose anything that doesn't appear on CT?
(just being the devil's advocate) actually a lot of the CTs performed in the US are really to appease the legal community more than medically neccesary. I have found the to be the consensus of every US physician I have met. A test that dissuades a lawyer isn't "good medicine."

Oh, and I know that Canada is now going to start letting it's subjects pay doctors to supplement the government run health services. Oh, and politicians in Canada are calling for it to adopt more US style health care. ..

So what? Canada wants to have some form of private pay in addition to its government sponsored one? Does that make the medicine performed better? If the Us is any indication, increased payments does not equate to increased outcomes. I am sure many will agree, politicians are usually not really good at making decision about much, much less medical decisions.

It's better than just telling them to go home and die, which seems to be the norm in much of the world..

First of all this is a pityful distortion and oversimplified. In many places I have been medical providers have accepted that there is not some mythical battle against death. The populations don't seem to think that the purpose of medicine is to live forever no matter what you have done to your body. There is a point where the quality of life you lead for a short while will be better than having you hooked up to every device in the hospital in an effort to turn you into frankenstein because you or your family seem to think people should only die on tv.

There is a point where a major surgery will not do anything significant for you. If you survive it at all. You might also find some of the best places in the US for various surgery rule out more people than they actually operate on. Keeps the success rate high. That is officially counted and published.

Or letting them die in a heat wave because all of the nursing home staff is on vacation. As happened in France a few years back.

Because the US never let anyone die in an environmental disaster because the medical system was totally overstressed?

A heatwave in Europe is an environmental disaster. No different that a flood in Idaho or a hurricane in the US SouthEast. I lived in Europe for several years and many buildings aren't even capable of mounting window AC units, central AC is not widespread either.

I'm also surprised that you knew so much about a patient that you weren't involved in treating.

Yea, people actually invite me to their institutions, give me an ID badge, show me around, and give me access to patient info.

I would actually be embaressed to not know a considerable amount about any patient I attended rounds on. But then again, I have professors who actually expect I can do things like review charts, formulate care plans, ask smart/hard questions, and be able to do more than just stand in the back of the room looking like I didn't know how I got there while tying suture knots with the drawstring of my scrubs hoping somebody would tell me what was going on.

 

[MrBrown]

I can see it now .... Brown will present his resume listing such things as

- House Officer
- Senior House Officer
- Speciality Registrar (Anaesthesia)
- 12 month secondment in Year 4 to helicopter emergency medical service

... they will look at me and go "so what, you seated people and took thier order or something?"

 

[medicRob]

Back to the topic at hand

Here is what the state of Tennessee protocols say about a physician on scene and how it is to be handled, taken from a screenshot of my "Paramedic Protocol Provider" app on my iPad.

 

[Simusid]

I find that quite hard to believe that a medic, especially one who has worked with a service for a while would not know who their medical director was. At my service, we see our medical director in the ER almost every shift. He stops in to say hello at the station, we have lunch with him sometimes. Then again, my service is allowed to RSI, Needle Cric, etc. so it is quite obvious why he would want to be actively involved as much as possible.

That being said, it was probably just a physician who arrived at the scene. In these situations, if they are not your medical director, you do not have to turn treatment over to them. If you do turn treatment over to them, they are required to ride with you to the hospital.

Ok quick followup/clarification/correction. It was a nurse at the receiving ER who yelled "who put in that central line?" *medic points at guy in back* "who is that medic? who does he think he is??" and it was Dr. X. The correction is that he was not the Medical Director at this particular time, but he is now. He told this story at rounds tonight.

 

[medicRob]

Ok quick followup/clarification/correction. It was a nurse at the receiving ER who yelled "who put in that central line?" *medic points at guy in back* "who is that medic? who does he think he is??" and it was Dr. X. The correction is that he was not the Medical Director at this particular time, but he is now. He told this story at rounds tonight.

As long as the doc rode in with you, it's on him, not you.

 

[jjesusfreak01]

Perhaps you could address if US medicine is so great why US citizens are going to Canada for things as mundane as prescription medicine?

Thats easy. Most countries other than the US regulate the drug industry and cap the prices on prescription medications. What this means is that in a country with national healthcare the government can tell the drug companies, "we will pay you this much for your drug, or we won't buy it at all". In poorer countries without national healthcare, they have to make the drugs cheap so that anyone will buy them at all. In the US people have private insurance that covers prescriptions and we have no means to collectively bargain with the drug companies, so while the rest of the world gets cheap drugs, the US is subsidizing it all.

You can see then why the drug companies vehemently oppose letting people get their prescriptions from Canada. If everyone did that, it would completely kill their profit margins. What needs to happen is the US government needs to get it together and tell the companies that they have to start charging the same amount in similarly developed nations. The US gets drugs cheaper, and they cost a bit more for everyone else, but at the moment, its US citizens getting screwed by the actions of the Canadians, Europeans...everyone with national healthcare.