It seems that all day, every day I care for patients who simply won’t take care of themselves. And I sometimes think that we in emergency medicine have caused more harm than we expected.
Now let me first say, I also take care of those who can’t care for themselves. There are those who, through age, infirmity or poverty simply have no means. The patient with a chronic condition who can’t see a specialist. The patient who has no family or transportion outside the ER staff and the ambulance. The demented, the mentally challenged, the broken children. Bring them on! All day, all night, I’ll give it my best and advocate for the rest.
But then, there are those who simply can’t be bothered. Who won’t pick up the antibiotic or antihypertensive after we search for the place they can get it for free. Who won’t keep the appointment with the specialist we spent two hours trying to arrange.
Those who won’t put down their phone to listen to what we say about their febrile child, then come back in twelve hours because ‘nobody did nothing, nobody told me nothing either.’
There are those who are frantic about their chest pain and upset that they can’t get their heart medicine but still smoke one or two packs per day even after we tell them, again and again, you have to stop. There are those who need us to treat their intractible vomiting but refuse their constant use of weed.
We have, in some ways, created this phenomenon. Part of the problem is also that people devalue what costs them nothing. A great deal of care in the ER is given away because it is covered government programs or simply by EMTALA. It has no cost, and no intrinsic worth to those receiving it.
We have created an enormously successful system of care that is timely and high quality. By being available and willing, tenacious and capable, compassionate and longsuffering, we have encouraged a kind of medical, even social, helplessness among untold citizens of this nation. Cut yourself shaving? Won’t stop? Meh, go to the ER. Menstrual cramps, like always, but they really hurt? Why NOT call 911? Sad (not suicidal) because of a breakup? An unkind word? Don’t talk to family, friend, pastor, priest or rabbi. The ER will know what to do! And (hope springs eternal) perhaps offer some pharmaceutical comfort to the situation.
Woke with a strange hot and cold sensation? Sweating and chilled? And endured it for an entire hour without taking anything? (Probably a fever, but who knows?) Vomited once? Baby coughed? Bug bit? Why wouldn’t you go to the emergency department? It’s the easiest thing in the world. And it’s what everyone else says to do. Call your doctor for a last minute appointment? ‘Yeah, you better just go to the ER.’ Call your dentist? Ditto. Ask almost anyone what to do in almost any situation and the answer remains the same.
And once there, medics, techs, physicians, PA’s, nurses and all the rest do the kind thing, the compassionate thing, even as we bite our tongues until they need stitches. We tolerate the general, learned (and chosen) incapacity of competent adults. In part because we believe it is a kindness. In part because, well, customers and all that. (And rest assured, customers who don’t know any better and have beat a well-worn path to the door are coming back over, and over and over. This is a behavior administrations want to encourage.)
I think about this and find myself frustrated. I find myself even more concerned. It reminds me of fatherhood. Now, I’m a pretty good doctor. However, I’m a Jam Up dad. And there have been times I have over-indulged my four children out of love. I still do as they move through young adulthood. I’m just that way. I’d do anything for them and their lovely mother.
Still, it hasn’t always been the right thing. Any good parent will tell you that children need some trouble and self-sufficiency. They need to learn to navigate problems. They need to develop the emotional reserve to deal with stress and to solve problems. They have to be educated and prepared to face crisis. To indulge, to solve every problem for them is to cause them irreparable harm in life. This is because we parents will one day exit. And it will be up to our sons and daughters to carry their families, their culture, their nation forward.
On the other hand, I don’t see a time when we won’t have hospitals, 24/7, providing anything, anytime to anyone in the US. It’s too ingrained. Too popular. Too lucrative. And too necessary for vast numbers of people; some who really need it, some who simply don’t know anything else.
One day we may face shortage, disaster, chaos. Just as our phone-addicted generations would melt-down if the Internet ceased, our ER addicted patients would be dumbfounded, gobsmacked, discombobulated and completely unhinged. I mean those who have abdicated responsibility, those for whom we have kindly solved every crisis and illness with no expectation of their growth or maturity. Those from whom we have demanded no ownership or accountability.
I’ve joked before that in emergency medicine, we stand squarely in front of natural selection and try to defeat it. But there’s a dark truth here. Not that we should let people die to advance evolution. But that struggle produces resourcefulness and advances growth and capacity.
And as long as we do it all for everyone, we may ultimately do more harm than good.
What hath emergency medicine wrought? Helplessness. And that’s a terrible, terrible unintended consequence of our self-congratulatory messiah complexes.