When attending to drug addicts you’re supposed to acknowledge the shame and loss of human potential while advising them knowingly.  You mostly know that they aren’t going to change.  That seems to be the one constant.  You should refuse to assist their indulgence out of principal while acknowledging how hard life must be for them.  Say, without actually saying, that you understand.  You understand that it’s not their fault life is a complete waste for them.  All the while holding on to your buoyant credentials and rising above it all.

I suppose the expectations lay persons have of health professionals make it more difficult to accept days when the elusive ‘it’ is not in us.  The days when one simply goes through the motions and depends upon habits and rituals to make it through.  Explanations are repeated over the years, practically verbatim, until they are almost meaningless.  It actually allows semi-down time when one can run on auto-pilot and become a robotic actor in a white coat repeating various scripts.  For patients who have these ’scripted’ discussions for the first time there is more meaning than most can imagine.  The meaning does not become lost on clinicians either, it is only the wow factor that seems to lose luster and become mundane.

This is one of many experiences that make it difficult to ‘have it in you’ everyday and keep interactions with patients fresh.  “Having your appendix removed is actually a very simple procedure, and it is in fact necessary.  Without it you will certainly become much more sick, and perhaps die”.  I used to imagine what it would be like to hear these words as though my own appendix was sitting in there inflamed and ready to destroy me from the inside out.  After a while I simply began to wait for the look of shock in a patient’s face as I repeated this dialog and he or she actually grasped the fact that surgery was to be performed right away and that the gnawing pain he or she hesitated to seek attention for was actually serious.  I’m pretty sure that I say it the same way each time, but people seem to have such different reactions that become triggered at varying moments.  Sometimes I ask out of curiosity what they are reacting to.  It’s almost always someone they know who died after surgery, how much it’s going to cost, or how much work they will need to miss.  Sometimes the big concern is who’s going to take care of their pets or children.  Pet’s seem to be harder to find care takers for in my experience.  I now have scripted responses  for each of these concerns, and various other questions as well (”Can i donate blood in case he needs it?”, “How big will the scar be?”, “Can it grow back?”, and “When can we start having sex again?”).

I go through my script, answer the now predictable questions, and raise my eyebrows at just the right moment to convey that yes I’m serious, and absolutely as concerned and moved as they are about their worm-sized intestinal appendage suddenly turning on them, and also the fact that kitty-cat is going to be so stressed and worried.  Of course I also add reassurance that everything will be ok (”barring any unforeseen circumstances” I also say, somewhat under my breath).  Even though it is a life-threatening condition, thank goodness it is completely curable.

Somehow, even on my worst days I can still pull off these easy straight forward cases, giving myself an A+ in all categories (efficiency, accuracy, compassion, problem solving, etc.) without much effort.  The cases that really challenge me on bad days are the manipulative narcotic seekers and morbidly obese patients with joints pains.  Neither can be fixed right away, both are self-induced, and these people turn to you with expectations that are simply unreasonable.  On my best days I try to deal with them as I would appreciate a doctor approaching me if I was in that situation.  I tackle their obvious major life issue head on, but with as much respect as I can possible muster.  On a good day it’s easy.  On days when these people seem to come in back-to-back-to-back, and have the nerve to become impatient while truly sick and dying people are attended to first, it is much more difficult to keep the professional mask firmly in place.  Still I try to maintain the thought that it could be any one of us in these shoes, even me.

If I am feeling really good that day I will ask them, “Is this the life you want for yourself?”  I will remind them that it would be much easier and faster for me to write an order for morphine, or dilaudid, or vicodin, or percocet, or anything else they may want than it is to actually spend time talking about how they might start making healthy changes in their lives.  I don’t BS them, I don’t say it’s easy, I try not to come from a position of superiority.  I just call a spade a spade and then let them decide if today perhaps 1mg of dilaudid instead of 2 or 4 might be a reasonable first step.  Perhaps throwing away every hostess product in the cabinet and starting to buy their snacks at TJ’s or the farmer’s market might be a reasonable first step.  I tell them about free activities I like to do on my days off, and what I ate for dinner the night before.  These are the moments that remind me that health care providers can do great things any day we choose to, when we have it in us.  I try to have as many of those days as possible.  It makes me feel connected.  It makes me feel like I’m actually giving everybody something, even if it is the same advice they could get from Oprah any weekday from the comfort of their own living room.  The fact is many of these patients need Oprah more than they need a doctor, and when I recognize that I try to become my own version of Oprah for that visit.

On days when I just don’t have it in me, I still take good care of patients (from a medical standard) and I just move on and try not to worry about my less than extraordinary performance that day.  I assume that I’ll just need some sleep, some time to regroup, and maybe a visit to the spa so I can come back next time ready to do great things.

2. There is an art to the practice of medicine that no statistics or government mandates will ever be able to harness or fully regulate. Sometimes doing nothing is the right thing to do, and not because of costs or available resources.

3. Medicine is not homogeneous enough to follow simple rules or algorithms across the board.  When people ask if an 80 year old with cancer will be ignored to treat a 40 year old with cancer, it fails to recognize that there are different forms of cancer with different stages and different prognosis, as well as different treatments.  Even if one decided to prioritize a 40 y/o with pancreatic cancer over and 80 year old with lymphoma the medications one uses to treat are different.  Even if we threw the kitchen sink at the 40 y/o he or she is still unlikely to survive for even 5 years.

4. Sometimes too much ‘health care’ can actually be detrimental to one’s health, especially the current care received by most geriatric patients when cared for by non-geriatricians.

5. Every rule ever created in medicine can be side-stepped by practitioners who find them inappropriate, for a medically justified reason.  For example, a patient with an aspirin allergy will not receive aspirin when having a heart attack despite the core measure requirements.

6.  Obama would not ‘ration’ care or allow that to happen.

7. Rush, and the other right wing watch dogs would shine a light so bright on any occurrence of rationing it would not be sustainable

8.  We currently ration health care, under various guises–pre-existing conditions, medical futility, experimental treatment, out of area resident, elective procedures, etc.

9. Bad doctors can not be counted on to do the right thing regardless of the health care paradigm in effect.

10. Good doctors will do the right thing regardless of governmental regulations and financial incentives.

Perhaps it is just a way to justify putting some of my needs first, but I think it is important to practice sustainable habits to be a good physician today, tomorrow, and ten years from now.  Burning out will do nobody any good in the long run.  Furthermore, burned out doctors have bad attitudes that patients remember more than any brilliant medical miracle one may perform.  There is a reason airlines tell us to apply our own mask first before attempting to help others.  If you run out of air yourself you will be absolutely no help to anyone else.  That passenger sitting next to you who can’t figure out how to put on a simple plastic mask is certainly not going to help you if you go down.

As a physician these shades of grey extend far past clinical duties and patient related decisions.  I recently reviewed a malpractice case.  The Emergency Physician had done an ok job.  It was just on the border of meeting the standard of care.  One could make a strong argument in either direction.  As I looked further into the details of the case, I read between the lines and understood the situation that doctor had faced.  He was essentially fed to the wolves.  The surgeon he asked to help would not bother to help, the patient had a very unusual presentation, and he was working in a very poorly functioning hospital system.  As I read through the case, and advised the plaintiff of my opinion I knew very well that I could have made thousands of dollars with very little work by just saying this doctor fell below the standard of care.  It didn’t even matter if the lawyer won or lost the case, I would still be paid well to argue that the standard of care was not met.  I chose instead to look at the case more realistically, and not place it in a black or white category.  Ultimately we decided it was not appropriate to pursue, and I lost out on thousands of dollars.  But I must say it makes me feel good.  It makes me feel like I did the right thing.  There have been many scenarios in my career where i have turned my back on thousands of dollars because it just didn’t feel like the right things to do.  At first I felt like a dumb ass for walking away from that kind of easy money, but now everytime I do I feel good.  I feel like temptation has come knocking again, and I politely decline and sleep well at night.  I can only hope that if my clean record and career are brought into question, the expert reviewing it will feel the same way and seek the truth even if it means doing the right thing will cost him or her thousands of dollars.

When Truman tried to establish Medi-Care it was effectively blocked until the 1960’s, primarily by the American Medical Association (AMA).  There was a very public campaign comparing government insurance to socialism and communism coinciding with, and likely accelerating, cold-war sentiments.  The AMA even opposed private insurance when it began to emerge in the early 1900’s.  It wasn’t until the depression left many patients unable to pay for medical services that doctors began accepting insurance routinely.  Anything that comes between patients and doctors has been traditionally viewed as a threat to physician autonomy, especially third parties who come between physician’s and their payments.

When congress finally passed the medicare act it did so with the AMA fighting tooth and nail,  openly threatening to boycott the program.  This anomosity is largely responsible for the inefficiencies and run-away costs Medi-Care and Medi-Caid are known for.  Without constructive input and collaboration from the largest and most influential medical society significant flaws and run away costs were inevitable.  In an attempt to appease doctors and convince them to participate in the program Medi-Care initially paid doctors almost anything they asked for, while doctors routinely doubled or tripled medical service fees when when billing Medi-Care.  At first there was nothing the governement could do but pay the bills as asked because doctors were needed for the program to survive.  Eventually Medi-Care began to cap payments and to set prices for physician services, so the next generation of doctors began feeling the squeeze, which has become tighter and tighter with each passing year.

At this point the AMA is still trying to close the fence when the horse has been out for 40 years.  As a matter of fact, the fence was poorly constructed in teh first place becasue the AMA would not help with its construction.  As a physician who cares for a substantial number of Medi-Care patients already, I would prefer the AMA focus on finding and supporting the best plan out there.   The bridges built in this process may be used in the future to modify whatever program is established, over time, to better suit everyone’s needs.  It is time we break the long established tradition of oppossing any program that lacks perfection.

What can be tough for us as ED docs is that most of us are very social by nature, and we like to speak our minds, which is not always appropriate.  This is true of any profession, but in the ED there is so much happening and crossing our visual fields every moment of the day that the dichotomy between what we say and our internal dialogue can be gynormous.  It takes true self restraint not to say, “what the hell were you thinking”, or worse, at least 5 times a day.  I still say it with my eyes and eyebrows sometimes, and fortunately that can not be quoted in a patient complaint letter.  It is a true art to sympathetically look a patient in the eye while fully realizing in the first minute of the encounter that the next 10 minutes will be a complete waste of your 15 years of education because a half blind 1st grader with ADD can tell that little cut doesn’t need stitches, just some neosprin and a band-aid, thank you very much.

The only time we can really let it all hang out without fear of judgement or reprisal is with other ED folks.  Everyone else sarcastically says or thinks, “oh great bedside mannor doctor”.   Well guess what, I learned what great bedside manner really is… it is listening intently when the information is important, and thinking about what your going to have for lunch when people ramble on about dumb stuff so you still look interested.  Oh I hear it, I hear it all, but instead of giving the natural look one should have when thinking, “I can’t believe you just told me your feces floated today but sank yesterday….and wonder what it means because so did your dad’s” the look is “hmmm that’s very interesting” while the thought is, “you crazy fool, you probably both ate the same food, but it really doesn’t matter because you’re here for an earache!”.

Now admit it, your first reaction is, “oh my goodness, that’s what doctors think when patients tell them really personal stuff”.  Well, this is just the tip of the iceberg.  Imagine the internal dialogue when caring for malodorous, disheveled, rude, patients who think it is appropriate to urinate on the waiting room wall in front of young children.  Only a comrade in the trenches understands what it means to put on the poker face, take these “medical emergencies” as seriously as is warranted, and still maintain a degree of sanity in one’s life.  So I salute everyone who has joined this illustrious club, and if we have nothing else we have a career full of the most interesting, profound, and sometimes amusing human interactions imagineable.

It takes an amazingly understanding spouse/partner/boyfriend/girlfriend/friend with benefits or even roommate to really understand what we professional vampires need to function and survive between night shifts.  For someone who has not had this experience him or herself, it takes a tremendous leap of faith to respect and adapt to our sleep needs.  It doesn’t always make sense, and it isn’t always consistent.

Sometimes ‘The View’ is exactly what it takes to mellow out after a night of death, destruction, and social misfits.  Other mornings it is a bowl of cereal, silence, darkness, and REM sleep as soon as possible.  What I need to recover and hit the ED running for the next shift varies from day to day and is as multifactorial as our current economy.  At the end of the day (or I should say at the end of the night) the need to relax and refresh, by any means necessary, trumps all else and relationship drama is definitely not a part of that equation.

It is no surpirse that a high percentage of ED docs get divorced, and many others chemically control their sleep patterns.  I myself have had more than one relationship go down the drain as a direct result of sleep interference between night shifts and I have tried to control my sleep patterns with various agents (all legal!).  For me personally, that method of sleep control is not worth the memory issues, or groggyness.  I do still wonder what would have happened to some of those relationships had there been no nightshifts in my life, but everything happens for a reason, and I now have a wonderfully understanding sweetheart who gets it, and that makes all of the night shift horrors just melt away at the end of the night, with no need for chemical manipulation of my circadian rhythms.  I really have no advice for docs and nurses who have yet to find a sympathetic partner or a way to balance this crazy world of Emergency Medicine, except to work less if you can.  I do, however, suspect that avoiding conflict between night shifts will probably extend the life of one’s relationships, and I intend to mutter these words after every nigth shift until I drift into dream land, “I love my job, it completes me and brings me joy and my sweetie is the most perfect human on earth, and does no wrong”.

Sometimes I ask these questions grudgingly because I’m not sure I really want to know the answer, especially if I am nearing the end of my shift and trying to wrap up, get out on time, and not leave too many loose ends.  I ask anyway because I simply must if I want to put the idea of an aneurysm or dissection out of my head and sleep well at night.  This habit has made some colleagues and co-workers roll their eyes at the big and time consuming work-ups occasionally prompted by this practice habit, but when the tests do reveal potentially catastrophic conditions it seems to justify all the negative scans.  The problem is what happens next.

Today my patient turned out to have a major dissection of her aorta, which is potentially catastrophic.  It was fortunate that we caught it, but it was unfortunate that almost every hospital in the state of California was unavailable to help her.  Our hospital has no thoracic surgeon to manage this condition.  No hospital with a thoracic surgeon had an ICU bed where she could be admitted.  After 4 hours and 30+ phone calls, I realized why many doctors don’t bother looking very hard for these things.  While there is some gratification in catching a life threatening diagnosis, before it is too late, there is also tremendous negative reinforcement for this particular job well done.

For hours after my shift was over I found myself pleading with hospitals up and down the state, and wondering how full these ICU’s actually were.  Were there really no beds, or simply not enough nurses.  Had nurses been sent home (or not called in) to save money and as an added benefit the ICU could legally decline any transfer.  Who knows.  At the end of the day we did find a hospital with both an ICU bed and a thoracic surgeon.  After I invested so much, and went above and beyond on my own time I hope those surgeons do the same for her.  I also wonder what obstacles they may encounter attempting to do so.

Medicine is easily 10 to 20 years behind almost every other industry in terms of technology. There are the usually excuses of not enough funding, and the need for patient privacy, but if credit card companies can maintain internet security and create user friendly interfaces in industries where hackers have infinitely more motivation to breech security systems then why can’t we?