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…

 

Fighting drug abuse in the ER

Fighting Drug Abuse

My latest column in the Greenville News.

http://www.greenvilleonline.com/story/opinion/contributors/2016/04/09/commentary-fighting-drug-abuse-er/82713082/

I have a lot of ER stories that involve drug addiction and drug seeking behavior. I knew a patient who intentionally dislocated his shoulder three times in one day to receive pain medication. Another had a friend who stole an entire dirty needle box in order to rummage through it for injectable drugs.
I have been told by patients that pain pills were eaten by dogs, stolen by neighbors, lost in car crashes, accidentally flushed down toilets and all the rest. People have pled with me because their normal doctor was out of the country. One individual (call him Bob) came to me and was denied narcotics, then returned two hours later with a woman’s ID and saying he was she (call her Carol). ‘You aren’t Carol, I just saw you.’ ‘Yes I am, I’m Carol and I’m in pain.’ ‘Get out,’ says I. The list goes on and on and every physician has a few of his or her favorites.
In the annals of American medicine, it turns out this was all rather new territory, at least in scope. My career began in the early 90s when there were (for various reasons, corporate and otherwise) powerful initiatives encouraging us to treat pain with more narcotics pain medications like Lortab, Vicodin, Percocet and others. We were regularly scolded for being cruel and insensitive about people’s pain when we, young and innocent as we were, expressed discomfort with this practice. I remember being explicitly told, more than once, ‘you can’t create an addict in the ER.’
We were told that pain was the ‘fifth vital sign’ and were taught to use a ‘pain scale,’ which you’ll hear to this day whenever you interact with the healthcare system. ‘What’s your pain on a scale of zero to ten with zero being no pain and ten the worst pain of your life.’ Most nurses can say this in their sleep. We developed smiley face scales for small children to use.
We learned to give narcotics regularly for various types of pain, when they had been previously reserved for cancer, long bone fractures or significant surgeries. Medical boards were encouraged to discipline doctors who were reported to under-treat pain. And hospital administrators, ever in love with the ‘customer satisfaction’ model, pressured physicians whose patients complained about receiving inadequate pain treatment. (High patient satisfaction scores have been studied and associated with poor outcomes, by the way.)
Although it’s difficult to quantify because physicians feared for their jobs, I’ve spoken to many physicians over the course of my medical and writing career who were told by their employers to give narcotics when requested or risk loss of income or of employment.
This happened even in the face of staff who knew the abusers. We used to keep files so that even new physicians could tell who the problem patients were. Eventually, we were told to stop. It was a kind of profiling and it was unacceptable. Always assume they’re telling the truth, we were told.
Sew the wind, reap the whirlwind. Since 1999 prescription narcotic overdoses soared, quadrupling over the period to 2014 according to the CDC. Over that period there were 165,000 deaths from prescription opioids, most commonly Hydrocodone, Oxycodone and Methadone. In 2014, over 14,000 people died from those drugs.
Now, the move is from condemning our insensitivity to questioning our judgement. Prescription drug abuse is a high priority for state and federal law enforcement, state medical boards, the Drug Enforcement Agency and The Centers for Disease Control (which recently released new, more conservative guidelines for chronic pain treatment).
States are using online prescription monitoring programs and many hospitals are putting policies in place to give as few narcotics as possible in emergency departments. It’s a Catch-22 of course, as some patients with legitimate pain are told to find pain specialists or family doctors, when they either have no money to do so, or have no physicians in the area taking patients. Thus, they circle back to the ER where we try our best to remain both diligent and sympathetic.
Physicians and hospitals are now engaged in a constant battle to combat drug abuse, to save lives and help empower the families of those struggling with addiction, who are desperate to help their sons, daughters, husbands and wives.
I hope we maintain our compassion. But I also hope that it keeps getting harder to walk into an office or ER and get addictive, lethal prescriptions.
Because it’s time for this nightmare to stop.

 

 

My Most Important Patient

Medical stethoscope on keyboard as symbol for administration and office

Listening for heartbeat of most important patient

 

This was my column in the March edition of Emergency Medicine News, as linked below.

http://journals.lww.com/em-news/Fulltext/2016/03000/Life_in_Emergistan__The_Most_Important_Patient.13.aspx

My most important patient requires my constant diligence. For this reason, I am seldom far away from him. Only a few minutes inattention and there will be problems. I cannot forget my patient; I am trained to attend to him constantly. I am a professional, and my patient is, ultimately, my customer and the customer’s service is paramount, I am told. I am reminded by policies and procedures as well, and there are those who will contact me, day or night, regarding failure to do what my most important patient requires.
In these 29 years since I started medical school, I have seen many wounded and sick patients of varying degrees of complexity and interest. Legions of fevers and columns of colds, tribes of chest pains and nations of bruises, entire cities of coughs, herds (as it were) of nausea and vomiting and battalions of sprains. Flocks of fractures and entire civilizations of chest pain. But none of them, not one, occupied me like my most important patient.
I was guided by teachers in urgency and priority, I was taught to hurry here, take time there, but always be attentive. I was shepherded by wise physicians before me, but never did any of them put a patient on a pedestal the way my most important patient has been. Neither snakebite nor sepsis, aneurysm nor arterial blockage, pneumonia nor parasite has ever been thrust before me as the most important patient…until now.
What could he have, you ask? What affliction? Who could he be? Of what importance? Celebrity? King? Judge or politician? Child of my own? Parent or priest? Hardly. Not one, not even captains of industry who endow hospitals, have the power of this patient.
This patient, this most important patient of all, stares back at me all day long. I examine and treat him with my hands and sometimes my voice as I stare intently back into his face. I wander off to other ‘patients,’ but all pale in comparison to this one. He violates all privacy and priority and knows absolutely everything. I see a chest pain next-door, or a pelvic pain across the hall; a weeping suicidal woman a few rooms down. I come back and tell my most important patient each secret. The sordid or tragic details of every life I whisper to him, or write upon his screen.
Once my hands loved examining other ‘patients;’ the shape of normal and injured bone, the sound of clear and diseased lungs, the nuance of stroke, the tenderness of the abdomen that took so long to understand. Now I have no time. I must touch my patient, enter the password and let my well- trained fingers run across plastic, not skin or bone. Or speak into his ear with a microphone, far more expedient than time wasted with others. Far more important and billable.
Every time I wander away, my most important patient calls me back; ‘hurry, hurry, tell me about the others! Don’t take too long!’ And others humans, more important than I am, remind me. ‘Don’t neglect your most important patient! Finish everything he needs as soon as you can! He is the key to all of our money! And if you don’t, we will fine you, or punish you in some other way for failing to care for the most important one of all! But make sure the flesh ‘patients’ are happy; give them a little time or they might be upset and not come back, and then what will you tell your most important patient?’
My most important patient is now everyone’s most important patient. He (or perhaps sometime she) is in charge. Sometimes he is shy and recalcitrant and will not wake up, will not look at me with his glowing eye. When that happens, nothing can happen. No orders for labs, xrays or medicine. He is an angry god, and when he is angry no one else can be happy. Sometimes he is confused and plays pranks on me, so that what I thought I said to him is turned on its head or made unintelligible. He is capricious that way; but ultimately far better than ‘people,’ who say and do things that my most important patient isn’t programmed to understand or record. He doesn’t like that, and forces me to do things in a confusing manner because he is angry.
And he is a time miser; he wants all of my time and those who brought him to me (or rather brought me to him, a kind of sacrifice) know that he is greedy and yet expect everything to run as before, when other patients were important.
But I know, and you know, those days are gone like electrons on a wire. Because now, the most important patient of all takes the most time and the most effort and the most diligence because data and billing and tracking and policies are what he does and his handlers love those things the way we used to love humans. And spoiled as my most important patient is, I believe it is unlikely that anything will ever be the same again.
Pity. Humans are interesting. But sick or well, they simply cannot stand in the way of data entry.

FEEMRS: Fancy Expensive Electronic Medical Records System

I was at a locums assignment yesterday using FEEMRS. (You know, ‘Fancy Expensive Electronic Medical Records System?) It was all kinds of busy, with wait times of many hours. And as I slogged along, relearning FEEMRS after a few weeks away, I realized that it takes about one hour of looking at that screen for me to become exhausted.

It’s just too ‘busy.’ Every bit of the screen seems filled with some data, some field, some time-stamp. Oddly, I struggle to find the triage note, the home medications, the history. I struggle to find whatever orders I have entered and to see if they have been completed. I throw my hands up trying to discontinue orders and I nearly weep when it’s time to discharge a patient, a process which takes far too long with various orders, time stamps, discharge instructions, medicine reconciliations, printer selections and all the rest. Honestly, it’s far easier to admit someone to the ICU than to discharge them. At least in terms of computer time.

That’s the thing about FEEMRS. The ‘flow’ is all off. Oh, it’s data rich. But it’s mentally exhausting. Too many clicks, too little useful data, not nearly enough ‘white space.’

Furthermore, there are the orders to sign and the charts to sign. And after you’ve signed them, there’s another place to sign. And if the nurse so much as helps them to the door, and enters that fact with appropriate time-stamp, ‘0300, touched patient on elbow at door,’ well it’s going to need another physician signature to validate the elbow touching event and document that it was necessary, approved and billable.

Docs using FEEMRS across the country are daily beset by hundreds of orders that require signatures the next day; things we didn’t even know were orders. ‘Placed bandaid.’ ‘Paged nursing supervisor for admission.’

A friend of mine was asked to sign nursing orders for psychiatric meds (Psychiatric Meds!!!), placed by nurses for hold patients three days after he went off shift. He wisely refused but was told ‘its OK, everybody does it’

By contrast, this year and last, I worked at TMH (Tiny Memorial Hospital and its several campuses) where I (gasp!) used paper charts or dictated to a human transcriptionist. My patient’s meds were either in front of me or one flip of paper away. My discharge instructions were a check mark away, or three clicks on a different program. And often, for orders, I check a box and handed it to a secretary to enter into the system. In some instances, my prescriptions were written by hand (not perfect) and could be ‘deleted’ or ‘reconciled’ with a simple tear of the paper.

I notice, now, that when I go back to my hotel room after working with FEEMRS, I sleep poorly. No wonder. I’m clicking and looking, scanning screens and logging on and off until 2 am. I tell my kids to stop looking at screens before bed or they won’t sleep well. I keep it up till the wee hours.

FEEMRS is quietly, slowly, electronically killing all of us and making us less concerned with patients than we are with fields, files, clicks and saves.

Something has got to be done…

I just do n’t know what.

If this is an emergency, hang up and dial 911…

birdbig-withWordsButtonon-web.png

 

Currently, in American healthcare, experts are wringing their hands in confusion.  I mean, people have insurance, right?  And yet, healthcare is still expensive and dang it, people just keep going to the ER.  Visits are climbing everywhere and I can speak from personal experience when I say that we’re tasked with more and more complex and multi-varied duties in the emergency departments of the 21st century.

I’m not a medical economist.  I do have some thoughts on the well-intentioned but deeply flawed Affordable Care Act. However, I won’t go there right now.  What I do want to address is the ‘go directly to the ER’ mentality of modern American medicine.

Call your physician.  If it’s after hours, the recording for any physician or practice of any sort in America will have a message:  ‘If this is an emergency, hang up and dial 911.’  It’s a nice idea.  But of course, it presumes that everyone really understands the idea of emergency.  In fact, they don’t.  We understand that, or we try to, but we see lots of things that come in ambulances, or just come to the ER, that really aren’t.

‘I feel fine, but my blood pressure is up.’

‘I was bitten by a spider and I watch nature shows and I know how dangerous they are.’

‘I have a bad cold and I have taken two rounds of antibiotics.  I have an appointment with my doctor tomorrow but I thought I’d just come on in to get checked out.’

The list goes on.  In part, it’s because we do a poor job of educating people about their bodies and their illnesses.  Online searches usually result in someone self-diagnosing Ebola or cancer, so that doesn’t help much.

But in part, it’s because the ER, the ED, has become the default.  Surgical patients are told to have wound rechecks in the emergency department.  Kids with fevers are directed there by pediatricians or family doctors or secretaries.  People who need to be admitted are sent in ‘just to get checked before they go upstairs.’  Or sometimes, so the physician on duty can do the negotiation with the hospitalist, rather than having the primary care physician do so.

Why is the ED the default? In 1986 Reagan championed and Congress passed EMTALA, the Emergency Medical Treatment and Active Labor Act, which says you can’t turn anyone away for reasons of non-payment.  Another well intentioned bit of government meddling, it never provided any funds for it’s expansive act of compassion so many emergency departments and trauma centers simply shut their doors.  You can’t see patients for free all day and still meet your budget.  I think something needed to be done, but it probably went too far.

Fast forward.  Insurance is expensive even when the government mandates it. Whether for fear of litigation or due to over-booked schedules everyone else can always send patients to the ED day or night for any reason.  We still function under EMTALA and that will never, ever change.  Patients have little to no expectation of payment when covered by Medicaid and know it (and thus use the ED for everything, and I mean everything.  We are seeing expanding life-spans for the elderly, but with more complex illnesses being treated and ‘survived.’   We have fewer and fewer primary care providers.

Who actually thought emergency department visits would decrease, and why?  Did they ask anyone who saw patients on a daily basis? Or only lobbyists, administrators and progressive academics with starry-eyed fantasies?

I want to take care of everyone. But the Titanic that is emergency medicine in America is sinking.  We really, honestly can’t bear the burden for all of the chaos of our national healthcare.  And don’t tell me that if we have a single payer system it will change everything, because it won’t.  EMTALA will go on and doctors paid by the feds will not be more productive than they are now, so everything will still flow to the emergency departments and trauma centers of the land.

This isn’t about rejecting the poor, or even criticizing Obamacare.  It isn’t about single payer or Medicare for all. It’s about entrenched behaviors and facing the reality of the system we’ve created which allows one part of the system to attempt to carry the limitations of the rest.

Herb Stein, father of Ben Stein, famously said:  ‘If a thing can’t go on forever, it won’t go on forever.’

And if its’ true anywhere, it’s true in the emergency departments of this great land of ours.

Where the answer to every crisis is: ‘hang up and dial 911.’

Don’t Freak Out! Be Calm in 2016…

Here is my column in this week’s Greenville News.  Enjoy!  (And call your grandparents…they love you.)

http://www.greenvilleonline.com/story/opinion/contributors/2016/01/10/dont-freak-out-calm-2016/78362386/

A common theme in the emergency department is this one: ‘Doc, I freaked out and came straight to the ER!’ I wish I knew how many times someone has said something similar to me. ‘The baby had a fever so I freaked out.’ ‘I fell and got a big bruise and I was afraid I had a blood clot so I freaked out.’ ‘I saw a spider on my leg and I freaked out so here I am!’

I’ve wondered about this for a while now. I have a theory. I believe that some of the freaking out that leads people to the ER results from the absence of sufficient grandmothers and grandfathers. It isn’t that those dear folks aren’t out there doing their best. It’s that families are often mobile or broken, disconnected from all roots. So the collective calm and wisdom of the ages, often found in grandparents, is often difficult to obtain.

I remember any number of my childhood injuries consoled, bandaged and painted with Merthiolate by my grandmothers. What I don’t remember is anyone freaking out. Not even when I nearly impaled my foot on a makeshift spear whittled from a broom handle.

In addition to ‘the grandparent’ issue, we really don’t do a good job of teaching young people about sickness, injury or even health outside of birth-control; even though life involves far more than reproduction.

The medical world of freaking out, however, is a microcosm of a greater problem. We seem to be a nation that ‘freaks out.’ We freak out over weather, politics, culture, relationships, celebrities and whether or not our own social media posts or pictures are getting enough traction. We freak out when life is difficult and we freak out when we’re bored because life is so good. And when we freak out, we go looking for someone to keep us calm, cover our wounds and give us hope.

Maybe we freak out simply because we watch too much television, where every medical event is a screaming, chaotic blood-fest. Or it could be that we spend too much time on the Internet, where every insect bite is deadly and every bit of swelling is (of course) the sure-path to cancer. Sometimes we freak out because of what we put in our minds. A patient once told me, in tears, that he thought about death all day. It turns out his television viewing exclusively involved shows about murder.

On the other hand, perhaps it’s more than being educated (by school or grandma) about all the the things which should make us ‘freak out’ or not. Maybe it’s a matter of how to deal with anxiety and uncertainty in general. I have observed over the years that children from chaotic home-lives are much more anxious when we have to stitch their wounds, start IV’s, give them injections or any other stressful, frightening procedure. Those who come from homes filled with consistency and calm can often be managed with simple reassurance. It could be that calm was the most important salve applied by grandmothers.

I believe in preparing for crises. I became a physician in large part because I didn’t want to be powerless in the face of medical emergencies. I say we teach young people as much as we can to prepare them for life’s troubles, whether they involve open wounds or flat tires. Knowledge is power, as they say.

But I believe we can help the ‘freak out’ crisis with two other things. The first is by keeping families connected and involved, so that the young can see how adults handle stress. It’s important to model this for our kids, well into their 20s.

The second, however, is a little harder. I believe that everyone needs a belief system to bear them through hard times. As modern, technological and scientific as we have become, we have yet to escape our deep need for hope and meaning, for transcendence in the face of trouble. And yep, I’ll say it; for a God who will calm the storm or calm us in the storm and be waiting on the other side of it, in this life or the next.

Life is hard and scary. But there’s way too much freaking out. And with the right application of grandma, knowledge and God above, maybe we can spend 2016 with just a little less freaking out and a little more hope.

 

The Leap Physician Satisfaction System

This is my column from the November issue of Emergency Medicine News.  Observations on keeping physicians professionally satisfied, healthy and happy.

http://journals.lww.com/em-news/Fulltext/2015/11000/Life_in_Emergistan__The_Leap_Physician.7.aspx

The Leap Physician Satisfaction System

I have never been the director of any professional group. I have, however, been directed. As such, I have a few tips for those who are directors and administrators. I give you my ‘physician satisfaction system.’ It is arranged in no particular order.

In every physician break-room or lounge, there should be a wall for photos of girlfriends, boyfriends, children, spouses, parents, dogs, cats, horses, boats, new shotguns or whatever makes those doctors happy. Emphasis on children and spouses, boyfriends and girlfriends, moms and dads. See below.

Post this where physicians work. ‘If you have a husband or wife, please avoid having a girlfriend or boyfriend. It is unfair to your spouse and children. And it is very, very expensive, as hobbies go. You’re better off with a boat.’

In every physician break room there should be: 1) a recliner 2) a refrigerator with snacks and drinks 3) a television with cable 4) a computer with Internet and without the silly hospital fire-wall. Pay for it yourself if you must.

Know your doctors. The best way to do this is to talk to them. It’s tough to really talk on a shift. The best way to do this is away from work. A quarterly group dinner is a nice touch. Or simply, ‘hey, let’s go to lunch one day and catch up.’ You have to mean it though.

Remember that a married doctor is a unit. When there are important decisions to be made (into which you and your partners are allowed input) invite your doctors’ husbands and wives to give their opinions. You’ll be grateful for the wisdom a loving spouse brings to the table. And remember, nobody is more motivated to make the group money than a spouse with a mortgage to pay and babies to raise.

If you really want to score points, send a card or note to the group spouses now and then. Thank them for their service, their encouragement, their patience. Ask them how their family is doing. Remember that being married to a physician ain’t exactly a pony ride. Everybody needs a kind word.

Attend weddings, celebrate births, have anniversary parties. Visit the sick in your group. Send condolences. Mourn at funerals. Laugh and cry. If you take the time to know them, it won’t be hard. They’ll be family.

Lead…from…the…front. If your docs tell you nights are really hard, work a string of nights. If they tell you that someone on staff is really hard to consult, talk to that person yourself a few times. (Tell those difficult doctors to back off and play nice.) If everyone hates the EMR, do everything you can to make it work for them. Never ask your ‘troops’ to do something you won’t. Never, ever.

Be fiercely partisan towards your guys and gals.

Help your doctors develop long-term plans, including an exit strategy. Don’t talk about it, do it. We can’t all go into urgent care or academics, but we can plan for a slow, steady withdrawal as the years go by. Encourage wise decision making, especially in the young Jedi.

Develop a sabbatical. Encourage your doctors on sabbatical to travel, take a class, enjoy sleeping in their own beds. It may be the longest time they’ve slept all night with their husbands or wives consistently in years. It may be the first full reset of their circadian rhythm since medical school.

Watch your doctors closely. It’s easy to become overwhelmed, depressed, anxious. Help them through mistakes. Let them decompress. Let them be sad. Don’t chastise, teach. Find a local counselor in case they need to talk about that death, that tragedy, their personal demons. Doctors kill themselves sometimes. Try to keep it from happening.

Identify the strengths in your doctors. Some are born leaders; let them move in that direction. Some are brilliant clinicians, use that. Some are great with people. Let them mentor. Some have hobbies or interests that make them better physicians. Celebrate the unique individual gifts that every partner brings to the table. Now and then, use these to remind the hospital what a unique and valuable team you have.

Take pride in your group. A logo and t-shirt would be a nice point of pride. Brag about your doctors. Tell the local newspaper about them. Help them be invested in the community, treasured by the community.

Praise your partners, both to their faces and to others. Write down the good things they do for future letters of reference.

Give your team permission. Permission to succeed, permission to fail. Permission to try new things and sometimes, permission to leave it all behind.

On really busy nights, call in pizza from home. On terrible nights, come in and use your authority to make things happen more smoothly.

There are a lot of schedules, in a lot of ED’s, with holes in the schedule. If you don’t want your entire group to realize this, and leave, and then come back making more as locums than they did before, then be their advocate.

We have a hard job. But with the right leader, it can be wonderful even when it is hard. It’s up to you, directors, to set the tone. Good luck and Godspeed.

Tell me about your little hospital!

I’m putting together a project on small hospitals.  While I’m particularly interested in critical access facilities in rural areas, other small facilities (urban and rural) are welcome.  I’ve always contended that big teaching centers get all the ‘love.’ There are television shows and books and movies about the enormous referral hospitals in big cities.  But not so much about the little hospital at the end of the road on the mountaintop, or on the windswept coast or in the desert Southwest.

And yet those places have dedicated staff who do great things, save lives, comfort the sick and do most of it on a pretty limited budget and in all kinds of weather.

So if you are interested in being part of this project (I’ll reveal more in time), tell me about your hospital.  Where it is, why it matters, its great successes and struggles.  If you have anyone I can contact there, please let me know that as well.

I want to hear your stories!

You can respond here or e-mail me at edwinleap@gmail.com.

Sincerely,

Edwin Leap, MD

 

 

 

Changing Conditions for Hospital Admissions (My Baptist Courier column for August.)

For subscribers to the Courier, here’s the link. For others, the text of the column follows.   (Link won’t open without subscription information!)

https://baptistcourier.com/2015/08/wholly-healthy-changing-conditions-for-hospital-admission/

When we take our sick or injured loved-ones to the hospital, we often hope that they will be admitted. In many instances this is a very reasonable request. When heart or lung disease are at work, when severe infections, dehydration, fractures or strokes occur, admission may well be the only option. However, sometimes our desire to admit our family members is a throwback to a simpler time in medicine; particularly where the elderly are concerned. I don’t know how many times I have heard this, or some variation: ‘Doc, I know you say she’s fine, and all the tests are normal, but if you could just put mama in for a few days so she could get some rest, I think it would work wonders!’

When I was a younger doctor, without reading glasses and a gray streaked beard, we called them ‘social admissions,’ but we all knew that they were often necessary for pain control, or simply because the patient’s home life was so horrific. In the days when people were generally admitted by their own physicians, it was simple stuff.

‘Hey Billy, Mr. Mason is feeling very weak. We can’t find anything wrong, but he just doesn’t walk well.’

‘Wow, Ed, that’s odd. He’s never like that! Let’s just watch him overnight.’

And it was a done deal!

Alas, it’s not that way anymore, and for a number of reasons. First, insurance companies, along with Medicare, are imposing much stricter controls on what they will pay for, both in and out of the hospital. Honestly, many things we used to do as inpatients can be done much more cheaply as outpatients (and without risk).

Second, health care costs are rising. As we live longer, as we learn to treat more severe illnesses and injuries and simultaneously extend health insurance coverage for more people, look for a lot fewer admissions to the hospital as insurers cut costs wherever they can.

Third, admissions are increasingly done by ‘hospitalists,’ who do only inpatient care. They do excellent work, but they are under enormous pressure to admit only what is necessary and to discharge patients as quickly as possible. Otherwise they (and their hospitals) have to answer to chart reviews and face denial of payment by insurance companies.

Finally, (and perhaps most important) we have less admissions because most of us in medicine have figured out that being in the hospital isn’t inherently safer. You see, in hospitals, mistakes are sometimes made. Medication mistakes, transfusion mistakes, surgical mistakes. Falls and other accidents happen. The modern hospital is a chaotic environment, and for all the heroic efforts of the staff, they are entirely human and their patients are remarkably complex, both adding to the risk of error. In addition, even the best hospitals harbor terrible viruses and bacteria which patients can contract from one another. One is well advised to avoid them whenever possible.

It would be nice if we could keep everyone who wanted to stay. Wait, no it wouldn’t. It would be terrible and crowded and unsafe! So the next time you or a loved one has a condition that might lead to admission, take a step back and ask, ‘is there any way to do this as an outpatient?’ The results might be just as good. Or even better.