Welcome new physicians! Watch where you step…

Today is the day that new resident physicians begin their training all across the United States.  Today, our future family physicians and pediatricians, neurosurgeons and emergency physicians, plastic surgeons and laser tattoo removal specialists (OK, not really a specialty, just a side-line) will begin learning how to be physicians, having completed four years of expensive college and four years of even more expensive medical school.  Anxiety-filled and debt-ridden, they will embark on four to seven (or even more) years of training to make them knowledgeable, technically proficient physicians.

I will occasionally wax poetic and philosophical for their benefit.  But not today.  Today there are practical matters.  Today I want to give them a few pointers, to ease their transition into the maelstrom of post-graduate medical training.

1)  Any flat surface that holds still, is free of gross body fluids and not used as a walk-way or cook-top will serve for a quick nap.  Practice sleeping in odd positions:  sitting upright, reclining at various angles, lying sideways or with your head cradled in your hands.

2)  In my day (always wanted to say that!) we filled our fresh, white lab-coat pockets with review books, algorithms, reference manuals, scissors and calculators.  And candy bars.  You, doubtless, have a smart-phone of some incarnation, which contains all that we had, as well as the Web.  Which means, where we had to play video games in the lounge and find answers in giant, antiquated things called attending physicians and books, you can look up fun facts on hyponatremia and instantly play Angry Birds, whether you’re on rounds, in the cafeteria or hiding in the call-room, pretending you didn’t hear ‘code blue.’

3)  Eventually, you may decide the lab-coat isn’t worth it.  Don’t be surprised.  Your kids will eventually wear it for Halloween.

4)  If you keep the lab coat, what with the extra space in your pockets, carry extra candy bars.  Or protein bars, or whatever it is you crazy kids snack on these days.

5)  Watch where you step.  Trauma patients and cardiac arrests are exciting!    But there’s almost always some body fluid on the floor when the shouting is over.  Try not to get too covered in blood early in your call night.  It’s sticky and gross.

6)  You know so much.  You don’t know anything.  Keep those two ideas in constant tension.  Odds are, your command of modern evidence-based medical research is extremely impressive.  Eighteen years after residency, I can still leave you in the dust when it comes to making decisions and knowing who is sick and who isn’t.

7)  See above.  Learn, as quickly as you can, who is sick and who isn’t.  Hopefully medical school helped; but don’t count on it.  If you know this simple thing, you will know when to go for help, when to panic (or not) and what to tell your upper level residents and attending physicians on rounds.  And you will become that greatest of commodities:  useful.

8)  Look professional, develop your own style.  Be comfortable.  My friend Sherri used to wear pearls on call, with her green scrubs.  They always made her appear elegant, no matter how much pediatric vomit had been hurled her direction.

9)  Patients can be frightening.  But remember what they told you at camp, about bears, raccoons and snakes.   ‘Don’t worry, they’re just as afraid of you.’  This is kind of true.  Except patients really aren’t afraid to ask for pain medicine or call attorneys, whereas you are afraid to do anything since you can’t believe you know anything yet.

10)  You may be more frightened of physicians than patients.  But remember, the people assigned to train you are smart, capable and experienced.  And they put their tentacles in their pants just like everyone else.  Ask them questions, listen and watch.  And remember what I said above:  be useful.  My surgery resident was fond of saying, ‘Help me, don’t hurt me!’

11)  You will soon have a thing called a paycheck.  It will have a stub that shows how much the government is taking from you.  Do not be surprised.  This happens to everyone.  It’s just that you owe a lot more money than most people.   Cheer up!  Everyone expects you to be rich someday, so they can complain about the fact that your rich.  (Whether you will be or not remains to be seen.)  Remember that no matter how little or much you make, never tell a contractor or car-dealer you’re a physician.  Tell them you work in customer satisfaction, or something nebulous like that.

12)  Crazy people, even really crazy people, are sometimes terribly ill.  Pay attention.

13)  Ill people, really ill people, are sometimes very crazy.  Pay attention.

14)  Medicine is inexact.  I promise you will make mistakes. Don’t live in fear, and don’t let error define you.  No one in medicine, or law, is capable of perfection.  Except for being perfectly insufferable, of course.

15)  If you poke things that look like they are filled with blood or pus, they will explode into your face; if you tend to hold your mouth open when you focus, well you know what will happen.

16)  Scalpels really are sharp.  Pneumonia and HIV and TB and Hepatitis really are communicable.  Psychotic patients really will try to choke you.  Medicine is dangerous.  Be careful out there!

17)  Human beings are really frail, vulnerable and hurting.  Be gentle and kind whenever possible.

18)  Have fun!  Don’t think of it as residency, think of it as a chance to spend most of your waking and many of your sleeping hours in a huge, cold-building where people are dying!

19)  Everyone is proud of you.

20)  Pay attention to what the nurses say.  They aren’t always right.  But for quite a while, they’ll be right more than you are.

21)  Only three to seven years to go!  Hang in there.  Remember, it’s no different from Boot Camp.  It just lasts much, much longer.

Pandora’s Pill Bottle. (A poem about the narcotic epidemic)

Pandora’s Pill Bottle

‘Patients who suffer from painful conditions
Should always be treated by caring physicians,
Who never forget to give good medications
For problems from fractures to awful menstruation.’

‘The fifth vital sign is your bright guiding light
The pain scale will lead you to do what is right,
So doctor remember to show some compassion
Since giving narcotics is now quite the fashion!’

Thus we were told for a decade or two
As patients stopped breathing and turned rather blue.
But hospitals loved their new high survey scores
And doctors were turned into pill-writing whores.

Yet things are now changing across the whole nation.
There’s blame all around and new drug regulations.
‘What were you thinking? What were you doing?’
‘How could this happen? Someone will start suing!’

In ER’s and clinics and every location
We docs shake our heads with increasing frustration.
We did what they told us despite all our fears
And Pandora’s Pill Bottle spilled out for years.

The pain scale betrayed us and caused too much trouble
The fifth vital sign is a big popping bubble.
The statistics we’re reading have left us quite nauseous.
So we’re trying new things to save lives and be cautious.

Dear doctors it’s you that must make these decisions!
Push back against administrative derision!
And when those ‘above us’ make policy errors
Stand in for the truth to prevent further terrors.

My column in the Winter 2017 Gray Matters, Newsletter of the Osher Lifelong Learning Institute at Furman University.

 

THE NEWSLETTER OF THE OSHER LIFELONG LEARNING INSTITUTE @ FURMAN

http://www.furman.edu/sites/OLLI/member-resources/Documents/GMJan2017-PDF_reduced.pdf

PAIN MANAGEMENT AND THE TIE TO ADDICTION – PART 2

Sometimes medicine offers us wonderful, almost unimaginable gifts. Heart attacks that were devastating, life-altering events a few short decades ago are now treated with an expediency and skill that our grandparents couldn’t imagine. A couple days pass, and the victim is home with stents in occluded arteries and directions to modify activity and diet. Pneumonia, once the ‘old person’s
friend’ (so called because it took the aged to eternity), is far less terrifying, thanks to both antibiotics and the pneumonia vaccine.

However, some of the things we do give benefits that are less clear. Although it could be an entire column in itself, the ‘stroke center’ movement, with the promise of miracles from ‘clot-busting drugs’, is a thing full of as many questions as answers. And what about depression and anti-depressants? When I looked up the side-effect profile of an anti-depressant a friend was taking, I was reminded that all of them have the potential side effect of increasing suicidal behavior.

But what about pain management? Thanks to improved understanding of the physiology of pain, the persistence of medical providers, and the investment and research of pharmaceutical companies, we have a wide array of pharmaceuticals available for the treatment of pain. Some are over-the-counter, like acetaminophen and ibuprofen. And others, those we refer to as narcotics or opioids (because in previous times they were derived from opium), are useful, potent, and (as is increasingly evident) fraught with danger unless used very cautiously.

Of course, for a very long time, physicians were taught to be judicious in prescribing narcotics. Our venerable teachers warned young doctors in training to be frightened of the side effects. We were especially aware of the very immediate danger that patients would stop breathing and die due to excess sedation. We were also aware that over time, patients on narcotics might develop problems with addiction.

About 20 to 25 years ago, that whole paradigm shifted and physicians were suddenly accused of callous disregard of suffering for prescribing too few narcotics. I remember this because I was in my emergency medicine residency at that time. We were constantly reminded to give more narcotics and be sensitive to pain. We were taught to use the ‘pain scale,’ in which a patient-reported score of zero meant no pain and a score of ten meant ‘the worst pain of your life.’ Never mind that it was entirely subjective and that there was no objective standard, no ‘painometer’ against which to measure it. We were instructed to see pain as the ‘fifth vital sign’ after blood pressure, pulse, respiratory rate and temperature. Of concern to many, these initiatives coincided with the development and aggressive marketing of ever more powerful, addictive medications like Oxycontin tablets and Fentanyl patches and lozenges.

Patient satisfaction surveys included the question ‘was your pain adequately treated?’ Physicians were castigated when those satisfaction survey scores fell. Physicians were instructed, by non-clinician

15

administrators, to give more pain medication to make patients more satisfied. (A satisfied customer/ patient is one that may come back!) Physicians who resisted, in the name of science or safety, were too often met with threats of reduced income or job loss if patient satisfaction scores fell. In some instances, physicians were (and still are) reported to state medical boards for alleged inadequate treatment of pain.

I sincerely believe that most of those encouraging us to write more narcotics prescriptions did so out of genuine concern and compassion. People are in pain, so why not treat the pain? In medicine, where science meets suffering humanity, it’s so easy for us to say, ‘Well, it just makes sense, doesn’t it?’ We assume that our compassion will be supported by our science. It happens with infections; sure it’s probably a head cold, but what’s the harm in an antibiotic to keep the patient happy? The child bumped her head pretty hard, so what’s the problem with a CT scan, even though she looks good? The parents are customers, after all, and want a scan!

With tragic consequences, our compassion sometimes causes harm as the Law of Unintended Consequences rears its ugly head. For instance, those antibiotics for colds? They can cause dangerous allergic reactions and life-changing intestinal infections requiring hospitalization or surgery, and resulting in death. Those CT scans everyone wants? Physicians are trying to reduce the number of scans, as many of us are concerned that they may induce malignant tumors later. And those pain medications? The evidence looks pretty damning.

Addiction to prescription narcotics is growing at a terrifying rate in the U.S. Likewise, death rates from narcotic overdoses have soared. The U.S. has seen 165,000 deaths from opioid overdose between 1999 and 2014. http://www.cdc.gov/drugoverdose/data/overdose.html. In fact, opioid-related deaths have now surpassed deaths from firearms in the United States. http://www.cbsnews.com/news/drug- overdose-deaths-heroin-opioid-prescription-painkillers-more-than-guns/ Admittedly, some of those deaths are not due to prescription opioids but rather to injected heroin. However, many heroin addicts began their addiction issues when taking legitimately prescribed pain medication.

Sadly, seniors are not immune. Physicians don’t want to see seniors suffer, so they often give narcotics even for pain that in decades past would not have been treated with those drugs. We give them for back pain, headache, arthritis, or other less serious conditions. And we use them extensively in treatment of chronic, intractable pain. In fact, in 2015, one-third of Medicare recipients received a prescription for an opioid analgesic; some 40 million prescriptions. https://www.statnews.com/ 2016/06/22/many-opioid-prescriptions-seniors/

Furthermore, seniors not only develop addiction, not only die from accidental overdoses, their narcotic analgesics have a host of side-effects, including (but not limited to) the following: excessive sleep, impaired thinking, increased pain sensitivity, nausea, constipation, and cardiac arrhythmia. In addition, opioid drugs contribute to weakness and loss of balance and thus to falls, resulting in head and spine injury, various fractures, and other trauma. Their already impaired reflexes are dampened by their medication so that for those who still drive, it becomes an even more dangerous activity than before.

No one is immune from this devastating epidemic, not rich nor poor, not young nor old. The medical profession, the mental health community, law-enforcement, social services, churches, families, and friends all have to come together and find ways to roll back the rising tide of death and addiction, which came as an unforeseen outcome of attempting to ease suffering with compassion and science.

This problem will be highlighted this spring at an OLLI bonus event, March 31, 2017: Seniors and Opioids: Unexpected Origins of a Greenville Epidemic. I will be speaking in conjunction with James Campell of the Phoenix Center addiction and rehabilitation facility. We really hope you join us to learn more about this pressing public health crisis.

Malpractice Isn’t a Sin

Dear physicians, PAs, NPs, nurses, medics, assorted therapists, techs and all the rest:

The great thing about our work is that we intervene and help people in their difficult, dire situations.  We ease pain, we save lives. Our work is full of meaning and joy.  However, we sometimes make mistakes.  But remember, in the course of a career you’ll do far more good than any harm you may have caused.

I know this issue lingers in many hearts.  I know it because it lies in mine.  And I’ve seen it in other lives.  I said this once to a group of young residents and one young woman burst into tears. I never knew the whole story, but I imagine there was some burden of pain she was carrying for an error she had made.

But just in case you too have lingering anxiety or guilt about some error you made in patient care, I feel it necessary to say this: neither honest errors nor even malpractice are sins.  They are mistakes, born of confusing situations, fatigue, inadequate experience or knowledge, overwhelming situations, the complexity of disease and the human body, social situations, systems problems, general chaos.  Born of your own humanity and frailty.  Your ‘shocking’ inability to be perfect at all times, and in all situations.  They do not make you evil, bad, stupid or even unqualified.  (PS If you’re not actually a physician but pretending to be one, you’re actually unqualified so stop it.)

As a Christian physician I have contemplated this over and over and have come to the conclusion that God knows my inadequacies and loves, and accepts me, regardless.  He has forgiven my sins.  I embrace that reality every day.  He forgives my pride, anger, sloth, greed, lust, all of them.  But he doesn’t have to forgive my honest errors.  Because they are not sins. Go back and read that again.  Your honest errors are not sins.

Mind you, all of the brokenness of this world is, in my theology, the result of ‘Sin’ with a capital S.  (Not in the sense of minute, exacting moral rules, but in the sense of the cosmic separation of the creation from the Creator.)

So, my mistakes, my failures are born of Sin, but are not ‘sins.’  If my mistakes, if the harm I may cause, come from rage, vindictiveness, cruelty, gross negligence, murder, drunkenness or other impairment on the job, then they could reasonably be due to ‘sin.’  But even so, those sins can be forgiven, and washed away with confession and true repentance.  (Not platitudes or superficial admissions of guilt, mind you, but genuine heart felt ‘metanoia,’ the Greek for repentance, which means ‘to change direction, or change one’s mind.’)

If you are not a believer, join us!  But if you aren’t interested, I love you too and want you to move forward, not burdened by unnecessary guilt.  If you are a believer, and a practitioner, remember that Jesus (The Great Physician) set the bar pretty high and doesn’t expect your perfection, only your honest, loving best.

Mistakes, even mistakes that rise to malpractice, are not sins.  But even if they rise to sin for reasons listed above, they are no worse than any other.  Which means Jesus atoned for them as well.

Move forward in joy.  You were forgiven before you even started worrying about it.

Now go see a patient. The waiting room is full of people who need you!

Merry Christmas!

Edwin

 

 

Rare Gems in the Rolling Seasons of Life

http://journals.lww.com/em-news/Fulltext/2016/10000/Life_in_Emergistan__Rare_Gems_in_the_Rolling.15.aspx

My column from the October edition of Emergency Medicine News

It’s August. I’m looking out the windows of our log house and across the immense variety of green leaves, on oak and birch, mountain laurel and sycamore, magnolia and honeysuckle. It’s a rain forest here. Indeed, after a long dry spell, we’ve had days and days of soaking rain, with breaks in the clouds so that the sun can raise steam from the earth like water coming up in the garden of Eden.

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But the greens have hints of yellow. And the clouds are not just summer thunderheads but low, fast, and broken. The dogs are lazier than normal, as their crusted red-clay coats begin to flake off to reveal the fur underneath. Even the cats seem less mobile, if that were possible. The evenings, despite the blast furnace of August, cool more than in July.

All in all, the signs are there for those who watch. I grew up watching the weather, watching leaves flipped before storms, listening to the sound of winter winds, smelling storms on the air. I know Autumn is hiding across the Blue Ridge Mountains, a child peeking over and shaping the weather, teasing us, reminding us that summer will soon go on its own vacation and the wind will chill us and drive down the leaves, their red, orange, and yellow as varied as summer green.

But for all my love of Autumn, for all my desire for cool air and the smell of wood smoke, Autumn hurts me. It is the end of summer and the beginning of fall that takes my children from me and forces them back to school and schedules. It’s difficult enough to leave them for work, more so to know that my schedule and theirs conspire to separate something so vital, so elemental, as the time families spend in communion with one another.

Even as I write, my daughter Elysa, a high school sophomore, is finalizing her summer reading. Her brother Elijah, a high school senior, is spending his last days with his girlfriend Tori, who leaves for the University of South Carolina all too soon. My oldest boys, Sam and Seth, will return to Clemson in a few days, closer and closer to independence. The leaves change, the sky is darker, the children are growing up and moving on, with the imperatives and requirements of their own lives, their own passions, their own needs and desires, their own loves.

As difficult as this can be, I recognize that I did the same, as did my wife Jan. And our parents and theirs. This is the cycle, the natural history of the world. We raise and guard our precious children and launch them forth to do the same. And we hope that the chords that tie us remain intact; that the circle remains unbroken.

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Time is Fleeting

What has any of this to do with our work? Our physician lives? The lesson is this: Time is fleeting; life and love are precious. Wives and husbands and children are rare gems in the rolling seasons of life. So waste not, want not, as it were.

The seasons will turn. The clouds race, the school buses arrive, and the graduations loom. In the midst of this, we must never delude ourselves that our money, our directorships, even our retirement accounts will ever be sufficient solace if we look back and feel that we did not use our time wisely with the ones who mattered most of all.

Our work, our patients, our skills all matter to the extent that they help others to live long and well, that they help those parents and children to enjoy the passing years together. Beyond that, they are important but less so than our own people, the ones we are committed to, bound to by vows and rings, by birth and blood, by adoption and choice.

So as the year turns and new opportunities and shifts arise, be honored. But be circumspect. Keep before you the fact that everything changes, but with attention and love, all of our connections can remain intact despite years and geography. If only we value them more than we do our certificates, degrees, incomes and positions.

The clouds will roll and the leaves will fall, my friends, and we might as well watch them pass with joy, not regret.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

EPIC Go-Live Day! And a prayer for wisdom…

Some dear friends of mine, at Busy Community Hospital, are having a momentous day.  Today is the ‘Go-Live’ for their brand new, shiny EPIC EMR.

For those of you outside the hallowed, creaky halls of medicine, EPIC is one of the most widely used electronic medical records systems in America.  It’s big, it’s expensive, it captures lots of data, integrates ER’s, hospitals, clinics, labs and everything else.  (Probably your cat’s shot records too.)

EPIC is also a company highly connected to the current administration; big donors to the President.  FYI.

The problem isn’t what you get out of it, it’s the cumbersome way you have to put it in.  In my opinion, for what that’s worth, EPIC is not intuitive. It takes a long time to learn to use it well.  I have never used it in a situation where it could be fully customized, but I’m told that makes it easier.  And admittedly, some docs and nurses truly love EPIC and are at peace with it.  I suspect they have implanted brain chips or have undergone some brain-washing.

https://giphy.com/gifs/zoolander-ac38RqTgQXYAM

Typically EPIC instruction occurs over weeks, as it has for my friends.  The first time I used it was in a busy urgent care, which was part of a large medical system.  And I learned it over one hour. On the Go-Live day.  So I’m sympathetic.

Thus, I have a prayer for those in the belly of the beast right now:

A Go-Live Prayer for those with new EMR systems.

Lord, maker of electrons and human brains, help us as we use this computer system, which You, Sovereign over the Universe, clearly saw coming and didn’t stop.

Thank you that suffering draws us to you.

Thank you for jobs, even on bad days.

Forgive us for the unnecessarily profane things we have said, or will say, about this process.

As we go forward, we implore you:

Let our tech support fly to us on wings of eagles and know what to do.

May our passwords and logons be up to date.

Protect us from the dreaded ‘Ticket’ submitted to help us.

May our data be saved, not lost.

Let the things we order be the things we have.

Shield us from power loss, power surge, virus and idiots tinkering with the system.

Give our patients patience to understand why everything takes three hours longer.

And may our prescriptions actually go to the pharmacy.

Keep us from rage and tirades.

Protect the screens from our angry fists.

May everyone go home no more than two or three hours late.

And keep our patients, and sanity, intact.

Great physician, great programmer, heal our computers.

Amen

 

 

 

 

 

 

A dark union: EMR meets EMTALA

Ah, EMTALA! The revered ‘Emergency Medical Treatment and Active Labor Act!’ It’s one of those things which is like a nursery rhyme to emergency medicine folks like me. We’ve heard about it from the infancy of our training.  ‘And then the bad doctor sent the poor lady to another hospital because she couldn’t pay!  And the King came and crucified him for doing it!’  The end.

EMTALA, for the uninitiated, is a federal law which ensures that we don’t turn people away from the ER because of finances, and also keeps us from transferring people to other hospitals without that hospital’s agreement.  It also exists to guarantee that we stabilize them as much as possible before they go.

I’ve said before, and always will, it was a good idea.  But like many laws, it was subject to the law of unintended consequences.  For instance, being forced to see lots and lots of people (who may not really be that sick), and do it for free, has huffed, and puffed and blown the hospital and trauma center down on too many occasions.  But that’s not my point here.

My point is that when EMTALA forms meet electronic medical records, chaos can ensue.

Allow me to illustrate:  This is a standard EMTALA form.  Check, check, check, sign.  It takes a busy physician less than a minute, and the nurses a few more since they have to call the other hospital and record times, etc.  This has worked well for a very, very long time.

img_3064

Enter EMR.  This is the procedure for doing an EMTALA form at Tiny Memorial Hospital, which has been enchanted by the dark Lord Cerner.  Mind you, I’m sure the ‘powers that be’ feel that this is a perfectly wonderful way to do the form.  Indeed, it captures lots of information and stores it in the system.  But two facts remain:  first, the people who designed the system generally work at Large Urban Hospital, which owns Tiny Memorial.  They don’t transfer things out very often.  They receive things.  Second, most of the patients being transferred are going within the system.  All the data is on the EMR, and it isn’t as if they’re going to some strange facility far, far away.

This, children, is the EMR based procedure (on a cheat sheet developed by a frustrated and confused provider):

img_3058

Not long ago my team worked a cardiac arrest at Tiny Memorial, with a successful return of cardiac activity.  Given our size and staffing, it took pretty much all of the staff available and nothing moved for a while.  A helicopter whisked our patient away.

Of all the things we did; drag her out of the car, do CPR, start IV’s, intubate, talk with family, chart, arrange transfer, nothing was as complicated or frustrating as this process to complete the EMTALA form.  In the end, I still got it wrong somehow.

Mind you, I never violated the spirit of the law in any way. She was treated, stabilized (to the extent of our ability) and sent away to a receiving hospital with the capacity to care for her.

I don’t want to impugn the motives of those who developed this.  I’m sure they were trying their best.  But if you don’t use it, you can’t see how hard it is. And you also can’t see how much time it takes in a place with limited resources and staff.

So please, folks, let’s use technology to simplify, not make things more complicated!  And let’s remember that charting isn’t the same as doing the right thing. And sometimes, doing the right thing isn’t perfectly reflected in the chart.

But paper or electrons, it’s still the right thing.  And that’s what EMTALA is about.

 

Thanks,

Ed Leap

Living the Locums Life: A Short Guide in Four Columns

Dear reader and locums travelers, past, present or future.  These are the four columns I have recently written for Emergency Medicine News as a series about locums emergency medicine.  For now, rather than post the entire text of each, or put them in four separate posts, I am lumping them together for your ease.

I hope you find this helpful!

Sincerely,

Edwin Leap

http://journals.lww.com/em-news/Fulltext/2016/05000/Life_in_Emergistan__An_Emergency_Physician_s_Guide.2.aspx

http://journals.lww.com/em-news/Fulltext/2016/06000/LIFE_IN_EMERGISTAN__Locums_Puts_the_World_in_Your.20.aspx

http://journals.lww.com/em-news/Fulltext/2016/07000/Life_in_Emergistan__High_Rates_and_Other_Perks_of.12.aspx

http://journals.lww.com/em-news/Fulltext/2016/08000/Life_in_Emergistan__Rules_for_Locums___Be.17.aspx

 

Dear Colleagues: you are not alone! (My column in the SCCEP newsletter, Summer, 2016)

http://www.sccep.org/

You Are Not Alone Guest Column: Dr. Edwin Leap

In this column, SCCEP Member and renowned columnist, Dr. Ed Leap, shares with us some heartfelt compassion and insight about being an emergency physician. Next month, SCCEP will award Dr. Ed Leap the Jack H. Warren Award in appreciation for his many years of leadership supporting the goals and missions of SCCEP and ACEP. Thank you Dr. Leap for your lifelong support of emergency clinicians (docs, nurses, techs) everywhere.

Dear emergency medicine physicians, You aren’t alone. This is very important for you to realize. I mean, I know you aren’t ‘alone.’ You have spouses and children, parents, siblings, neighbors, dogs and cats. That’s all good. You need them.  Also, every shift is chock-full of people and their maladies, which you heroically manage day in, day out. Patients are everywhere. Some are sick and some are injured, and many are addicted and a few are just lonely. They’re inescapable. And nurses. They’re all around also. The ones who carry out your orders, tend to your patients, sometimes ignore what you say and constantly interrupt your train of thought by putting EKGs in your face and shouting ‘Chest pain in room three will you see it!’ Or who constantly ask you ‘is the order in yet?’ You can’t escape them. Even a trip to the restroom will result in a phone call in short order.

Furthermore, there are students and residents to educate, and shape into excellent doctors. (Without killing anyone.) And there are consultants too. The ones who tell you ‘call me when the workup is finished,’ or ‘why didn’t you get the phosphorus level? How can I know what to do without the phosphorus level! Jeez!’ And there are those who refer patients to you. ‘Hey buddy, my patient has pneumonia and needs to be admitted to the hospitalist and has a bed but I need you to check him out first.’ The ones who send you their post-op complication one hour after the surgery.

There are other people all around too. There are administrators and managers, credentialing ladies, people tracking your times and your efficiency and evaluating your patient satisfaction scores. There are medical records people and coders tracking you day in, day out, to keep you on point with the endlessly important charting and billing that are the main purposes of your decades long education. Dear doctor, you aren’t alone. But not because of all of that.

Not because you’re under more scrutiny than at any time in the history of medicine. What I mean is, having traveled this great land of ours doing locums, I assure you that the struggles you face are present everywhere.  Oh, they vary in degrees. Those little oases untouched by the icy hand of EMR can be positively pleasant in their lack of complex charting requirements. And on night shift, in the middle of nowhere, in the mountains, there’s a paucity of people in general. But there will still be complex social situations, still be drug addicts, still be someone who wants to know about your door to needle time. Everywhere you go, there’s ‘that doctor’ who is simply surly and impossible to please when he’s on call.

When I say you aren’t alone, what I mean is that we are a fraternity (or a sorority if you wish). Perhaps better, we are a tribe, a clan, an extended family. Emergency medicine is a small specialty but what we do is so consistent across the country, and around the world, that we can all sit down at conferences or meetings, in airports or over dinner, and share the same stories, the same sorrows, the same laughs over the same archetypes. So when you come home and think that you’re the only one who thinks about quitting, you’re wrong.

We all do it now and then. When you think that maybe you’ve lost your patience with drug seekers, you’re wrong. We all lose it now and then. (I’m not proud…so I won’t go into it.)  If you think that you’re not fit for night shift because you feel terrible after being up, trust me you aren’t alone. Nights make everyone nuts. (As does day shift…and evening shift.) It’s a wonder we don’t all need psychiatric evaluation after long strings of sleeplessness coupled with complex care of the arguably the most demanding people on earth.

Are there days when you just want to go home and cry? Normal. Are there shifts you think you didn’t really know what was going on with anyone? Ditto. (PS, it usually means nothing was going on except drug seeking and the pursuit of work excuses.) Have you wanted to invite your on call specialist to the parking lot for a ‘come to Jesus meeting,’ and you think you have a problem? Nope, I’ve been there. And do you think that you might be the only physician with an EMR ‘inbox’ that’s full to the brim with requests you can barely understand? You aren’t. In fact, I suspect that delinquent charts have exploded in the last few years as charting becomes more and more complex.

Ladies and gentlemen, are there times you think you should have studied harder and tried for that ophthalmology residency? Haven’t we all. You aren’t alone. You aren’t alone in your troubles. But more important, you certainly are not alone in being part of the baddest, toughest, most compassionate and courageous group of physicians in the world.

You’re tough, you’re kind and you’re smart. You endure, no matter how hard or complex the shift, no matter how badly you feel.  You’re weary and irritable and pale. You’re hungry and thirsty and sometimes confused.

But kids, trust me. You’re awesome.

And you aren’t ever alone.

Doctors and Nurses ‘Getting in Trouble’ too easily…

Trouble

 

My column in the April edition of Emergency Medicine News

http://journals.lww.com/em-news/Fulltext/2016/04000/Life_in_Emergistan__Doctors_and_Nurses_Getting_in.6.aspx

Are you afraid you’ll ‘get in trouble?’ It’s a common theme in America today, isn’t it? We’re awash in politically charged rhetoric and politically correct speech codes. Our children go to colleges where there are ‘safe spaces,’ to protect their little ears from hurtful words and their lectures or articles contain ‘trigger warnings’ so that they won’t have to read about things that might upset their delicate constitutions. All around that madness are people who are afraid they’ll ‘get in trouble’ if they cross one of those lines. I mean, one accusation of intolerance, sexism, genderism, agism or racism, in industry, government or education, and it’s off to the review panel for an investigation and re-education!
Worse, I see it in hospitals now. I hear so many nurses say ‘I can’t do that, I’ll get in trouble.’ I remember the time I asked a secretary to help me send a photo of a fracture to an orthopedic surgeon (with the patient’s consent, mind you). ‘That’s a HIPAA violation and I’m not losing my job to do it!’ OK…
There have been times I’ve said, ‘please print the patient’s labs so they can take it to their doctor tomorrow.’ ‘No way! That’s against the rules! I’ll get in trouble!’ Seems rational. The patient asks for his own labs and takes them to his doctor. It can only be for nefarious purposes…like health!
Sometimes it’s even sillier. Me: ‘Patient in bed two needs an EKG!’ Nurse: ‘You have to put in the order first, or I’ll get in trouble.’ In fact, this theme emerges again and again when I ask for things like dressings, splints, labs or anything else on a busy shift. I’ve expressed my frustration about physician order entry before, and I know it’s a losing battle. But when there is one of me and three or four of them, and ten patients or more, it’s hard to enter every order contemporaneously. But I know, ‘you’ll get in trouble.’
I remember being told, by a well-meaning (and obviously threatened) nurse, ‘if I put on a dressing without an order it’s like practicing medicine without a license and I can lose my nursing license.’ Well that makes sense!
I overheard a nursing meeting not long ago, and it seemed that the nurse manager (obviously echoing her ‘higher-ups’) was more concerned with making sure the nurses didn’t do wrong things than with anything touching on the actual care of human beings.
I suppose it’s no surprise. ‘When all you have is a hammer,’ the saying goes, ‘all the world’s a nail.’ Now that we have given all of medicine to the control of persons trained in management, finance and corporatism, that’s the thing they have to offer. Rules, regulations and ultimately threats.
Of course, ‘getting in trouble’ applies to physicians as well. It just takes a different form. Didn’t get that door to needle, door to door, door to cath-lab, door to CT time? We’ll take your money. Didn’t get the patient admitted in the committee approved time-window? We’ll take your money.
Never mind that seeing patients in a timely manner is rendered nigh impossible by the overwhelming and growing volumes of patients, coupled with the non-stop documentation of said patients for billing purposes. Keep shooting for those times! Times are easier metrics to measure. Times are easily reported to insurers and the government. Times, charts, rules-followed, rules violated. The vital signs of corporate medicine in America today. (And don’t give me that ‘it would all be better with the government in charge.’ Two letters give that the lie: VA.)
No, we’re an industry constantly ‘in trouble.’ But not really for any good reason. We give good care as much as we are logistically able. We still save lives, comfort the wounded and dying, arrange the follow-up, care for the addicted and the depressed. We still do more with less with every passing year.
But odds are, we won’t stop ‘getting in trouble.’ Because for some people, waving the stick is the only management technique they know. Still, it saddens me. I’m sad for all of the powerless. The nurses and techs and clerks and all the rest who are treated as replaceable commodities by administrators who are themselves (in fact) also replaceable. I hate to see nurses, compassionate, brilliant, competent, walk on egg shells in endless fear, less of medical error than administrative sin. Their jobs are hard enough already without that tyranny, leveled by people who should appreciate rather than harass them.
And it saddens me for young physicians, who don’t remember when being a physician was a thing of power and influence in a hospital. They, endlessly threatened and unable to escape thanks to student loans, are indentured for life, short of a faked death certificate.
Finally, it saddens me for the sick and dying. Because we cannot do our best when our motives are driven by fear more than skill and compassion.
The truth is, however, threats only go so far. And once people have been threatened enough, there’s no telling how they’ll respond.
Just saying…