I wrote this piece, and published it in Emergency Medicine News, in 2001. Since that time, in the last 17 years, federal regulations (that is, obligations) have caused the closure of far too many emergency departments. Physicians are being subjected to censure by CMS, JCAHO and tracked like Caribou by Press-Ganey, all for treatment failures (even if the failures are due to patient compliance). Hospitals are constantly watching out not to violate government mandated treatment guidelines. Physicians are expected to see many patients in hospitals either for free, at markedly reduced Medicare rates or criminally reduced Medicaid rates. Patient satisfaction scores, the Holy Grail of administrators cause physicians to do whatever they are told by patients, in order to attain good scores and maintain their jobs and incomes. And there’s compelling evidence that this has contributed to the opioid epidemic.
Maybe I wasn’t so far off in 2001!
The Suffering Prevention Act
Dr. Sam Fisher walked into the small exam room with chart in hand. He looked up, and extended a tired hand to the well dressed gentleman on the exam table before him. Mr. Mason, I’m Dr. Fisher. What can I do for you? he said for the 35th time that evening. Without a pause, Roger Mason looked at him, and said the words that had become so common. I claim the right to free care and to your voluntary effort as guaranteed by the Federal Health Care Rights Charter. Sam Fisher knew that he was required to reply in one manner and one manner only. I am here to serve you. What is your need?
Roger Mason looked at him with a disdain that seemed to ask if there were any other doctors available. I’m in pain, as if you shouldn’t know by now. He looked down at his manicured nails, straightened his silk tie, and returned his gaze to the physician who stood before him.
Where is your pain, Mr. Mason? Can you describe it?
I have a hangnail in my left thumb, for one thing. Because of it I am using my right hand far too much, and my shoulder and neck ache. I work in marketing, and sitting at a desk all day with my arm on the armrest is causing me terrible discomfort. Furthermore, I have a pain in my knee from playing racquetball at lunch yesterday. But that’s nothing compared with the pain of my life in general. My wife expects far too much of me. I’m in love with my new secretary, who thinks I’m ancient. My job is dull, and there’s little room for advancement past vice president. I have bad memories of my childhood. My hair is thinning. I’d like to be numb, if you think you’re capable of doing it.
Numb? For how long?
A few days. But I demand a nicer room than this. Now run along and get my drugs.
I haven’t examined you, sir. I’d just like to make sure that you don’t have any life-threatening emergencies.
Do you think I’m stupid? I’ve researched my problems on the web. Don’t play high-and-mighty doctor to me. The law says that you are required to treat my pain. And the Suffering Prevention Act defines pain as whatever I tell you it is. Are we clear on this? Do I need to file a complaint with the Institute of Medical Regulation?
Dr. Fisher felt his heart race. The institute was composed of private and government agencies committed to the oversight of physicians. It had enormous power, and could suspend licenses, seize property, or imprison doctors on minimal evidence. It wielded the power of a high court, without a jury or representation of defendants. He recalled his friend Kristen from residency. One of the first cases the institute had prosecuted, she had refused to give a work excuse to a well-placed patient with a hangover. She spent three months in jail and three more in re-training.
That won’t be necessary, really. I’ll send a nurse in just a moment.
That’s better, said Mr. Mason.
Leaving the room, Dr. Fisher walked to the main desk to enter his orders. Years ago he would have complained about this man bitterly. Now, as he walked past the uniformed privacy monitor, he bit his tongue. He knew that it wasn’t worth the risk. He had children to raise, after all. He and his wife wanted to travel a little someday. Losing his job wouldn’t be worth it.
He logged onto the orders computer. A message waited for him. Dr. Fisher, you are scheduled for a review of your medical errors at 0600 tomorrow. Be prompt. The Commission on Hospital Function conducted reviews of all physicians. He wasn’t sure who scheduled the meetings. He would be working until 0700. If he left his post, he would be fired for certain. If he were late to the review, he would be censured and fined. He realized he would have to send some apologetic e-mails to rearrange things. First things first, however. He ordered the standard Morphine PCA pump, with the hallucinogenic additives whose contents were known only to government researchers. They were used in everyone with complaints of unhappiness, everyone who desired the numbness that Mr. Mason wanted. He arranged for him to be admitted for five days, with re-evaluation at that time by contentment consultants. Dr. Fisher then filled out the templates that gave his patient temporary disability, suspended his credit payments, and activated the Social Services Corps to go to the Mason home and help with the children. Rights are rights, he thought to himself.
He had heard of physicians who claimed that they were in pain, who claimed that they deserved the same protection and rights as everyone else, and that they needed to be freed from the weight of their many duties for a while. He knew of one who worked for housekeeping. A brilliant surgeon, he now emptied kick-buckets in the OR. No, there was no recourse. Retirement was the only hope, but that required diligence. Physicians who retired too early donated half of their retirement accounts to the Fund for Fairness in Outcomes. The rest were reviewed, and their money taxed according to how well they had complied with the regulations explained to them every week of their careers. The free-thinkers, the big shots ended up with barely enough money to avoid soup kitchens, their dreams broken by their arrogance. It wouldn’t happen to him.
He dreamt of the day he would walk out for the last time. Of the last time he would hear the invocation of rights, the last mention of oversight, error, or the institute. He heard, in his troubled dreams, the reminder from medical school. You have been chosen to serve mankind. Be grateful, and keep your mouth shut. He had really wanted to be an astronomer, but the Civil Medical Conscription Service contacted him at 18, and it was all history from there. But it couldn’t last forever.
Doctor, are you asleep? said the soft voice of the unit secretary. Doctor, may I remind you that I am required to report any dereliction of your duties as well as any attempts to avoid patient contact? Mr. Mason has summoned you.
No, Beth, just daydreaming. Thank you for the reminder. He rose to walk to Mr. Mason’s room, as Beth said behind him, Use of first names is a form of sexual harassment, sir. He turned the corner to find his patient standing in the hallway, angrily tapping his foot.
What do you call this? This dose you gave me? My records clearly indicate that I require more medication to achieve numbness. Don’t you realize that?
Mr. Mason, I’m sorry, but the Prying Eyes Act does not allow me to view your records without you being present and consenting. You were anxious for your medication, so I went to order it and fill out your forms.
Lies and excuses. If only you had asked me, I would have told you. I’m filing an action against you.
Disbelief, of course!
Sam Fisher shuddered. Disbelief was the worst complaint of all. It implied that the physician did not believe the patient, and was in effect calling him a liar. It implied that care was compromised by a physician interjecting his own opinions into the encounter, rather than acting as a conduit of services to the person in need.
But I did believe you! I did! Please don’t do this! I’ll go and order more right now!
Now you’re lying to me. I’ve already filed over the monitoring camera. You’ll learn your lesson now, Mr. Pompous Doctor!
Dr. Fisher glanced behind him, and saw one of the cameras that recorded all patient-physician encounters. Every one was permanently stored and retrievable. He hung his shoulders and turned. The inquiry would come. He would lose, as physicians always did in these things. Maybe he could hope for a simple loss of income for several months. Maybe he would be sent away. Mr. Mason laughed out loud and began to hallucinate pleasantly as his medication warmed his mind. Before he returned to his room, he remembered something he needed to say. Doctor, what do you say?
Dr. Fisher looked over his shoulder, and breathed deeply. Thank you, sir, for pointing out my error.
He left to await the investigators, as Mr. Mason slumped into his bed, and exercised his rights in multicolored dreams.