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…

 

Some things we need to do differently in hospitals.

Walking around the ER in Tiny Community Hospital, I had a few realizations.  In medicine, we hold onto some things very tightly.  We love tradition, we love the known.  We don’t always know why, but we choose ‘the devil we know,’ almost every time, no matter how pointy his horns.

For instance:  ‘No cell phones.’  First of all, has anyone ever seen a cell-phone interrupt anything we do?  No?  Neither have I.  Admittedly, cell phone use can be rude.  If I’m talking to a patient, I don’t want them ignoring me by taking calls or texting to the exclusion of our interaction.  And if I were a patient, I wouldn’t want my physician or nurse to do the same. But honest to goodness, cell phones are ubiquitous.  We communicate with them, schedule with them, navigate with them, learn with them and we entertain ourselves with them!  Even the sign that says ‘no cell phones’ is laughable.  Courtesy?  Please.  But let’s stop deluding ourselves that we can, or should, keep anyone from using their phones while they wait, sometimes hours, to be seen and treated.

How about HIPAA?  Great idea, privacy and all that.  But it has been done to death.  And the unintended consequence is that we have far too many log-on screens and passwords.  Furthermore, our computers time-out so fast we can’t keep up!  And yet, the real threat to privacy isn’t some poor knucklehead looking over our shoulders.  It’s corporations and government, insurers and ‘important’ people who see, and who may share, our most private information.  And none of them are defeated, or indeed affected, by passwords or anything else.

Another bit of silliness:  the idea that a family member or friend isn’t allowed to translate for someone who speaks another language.  Yes, it’s nice to use a service. But the contingencies of time and cost sometimes leave us with little choice other than 1) speak really loud and hope it gets converted into their language or 2) let someone with them do the talking.  In this instance, better is truly the enemy of good.

One close to my heart is the maddening way we treat test and xray results.  Having gone through cancer with my wife, I know the horrors of what we called ‘scanxiety.’  Waiting to know the answer can be heart wrenching. Fortunately, I was connected as a physician, and I was frankly a pain in the neck.  I got the answer as quickly as possible.  But for others, the waiting can be horrible.  Recently my dad had a CT of his lumbar spine due to severe pain.  It took days and days to get results.  Ridiculous.  In 2015, there is no reason for tests results to take two weeks; rarely even two days.  Unless the test is some exotic lab evaluation that has to be sent to East Egypt, we know the results the same day.  Making our patients wait is simply disrespectful, or slothful, or both.  Information travels at the speed of light people; let’s treat it that way.  The days of carrier pigeons and the Pony Express are long gone.

Finally (for today), there’s mental health.  We have woefully inadequate numbers of beds and psychiatrists and counselors for the mentally ill.  And yet, emergency departments have to hold vast numbers waiting on beds that will never materialize, and hiring sitters to do crossword puzzles while the mentally ill (or the pseudo-mentally ill manipulative) sit in bed and take up space in overwhelmed ER’s. We need a better system, sure. But we also need tort reform so that it isn’t so scary to discharge people.  And so we can stop doing a worthless dance that doesn’t make anyone better but merely imprisons them in uncomfortable beds in uncomfortable departments without anyone to actually talk with them.

Anyone else have a few?  What antiquated ideas, what anachronisms do we cling to in medicine?  And why should we jettison them?

Edwin

 

Online ACLS resources from Med Training Solutions

If you’re a busy clinician, whether physician, nurse, mid-level or medic, you are constantly bombarded with someone holding a clip-board, or sending an e-mail, reminding you of yet another requirement that must be met or updated.  ACLS, BLS, the list goes on and as soon as one is finished, it always seems to me that another is due!

Here are some links to online ACLS training through Med Training Solutions.

Have a look!  Med Training Solutions’ products may be just the ticket to your educational and credentialing needs.

ACLS Training videos: https://www.acls.net/videos.htm
– ACLS Algorithms: https://www.acls.net/aclsalg.htm
– Upcoming changes to AHA recommendations https://www.aclsrecertificationonline.com/2013/07/17/888/
– Sample course https://www.aclsrecertificationonline.com/login/

Have a great day!

Edwin