Here’s my Emergency Medicine News column for December.  Although you’ll see it in print this month, it won’t show up on the EMN Website for a month or two, so I offer it here.

A stocking full of truth!

Merry Christmas to all!

I was trying to think of what I could give you, as a kind of gift for the season.  I love getting gifts and I sure love giving them.  But the readership of EMN is pretty large and with four children of my own, it would be a financial stretch for me to send you a stuffed animal, toy soldier, book or pocket-knife; a bracelet, pen or watch or any of the things I enjoy giving.  So I was thinking between patients the other day about the things I can give you.  And I figured it out.  I can give you some truth.

One of the things I have always loved is truth.  I love absorbing it in books, in quotes, in lectures and sermons.  I love passing it on to my children.  I love hearing learning the truth in tiny snippets; the sorts of things I scribble into my notebooks, or write in the margin of a book.  I love the way it leaps out at me in interactions with doctors and patients; and the way novelists and poets can ambush me with it while I’m skipping innocently through a book.  The truth is a gift that’s hard as steel, sharp as a razor and absolutely critical; at this point in history perhaps more than at any other.

I enjoy writing for you because I enjoy writing the truth.  I have tried to convey it over the years, and you have all responded wonderfully.  We share a passion, you and I, for the unspoken, the obvious but neglected, the ‘great purple elephant’ in the room that no one wants to mention for fear it may get its feelings hurt.

So, fifteen years into my practice, and 8 years into my writing career with EMN,  I think I have some collected truth and a few ‘rules of thumb.’ I hope you enjoy.  Don’t expect anything under the tree…I’m working Christmas Eve!

1)  The key to competence is compassion.  If we don’t truly care for the well-being of our patients, no double-blinded, placebo-controlled, randomized study will make us better.  And no system of time-outs, prompts or algorithms will substitute for our developing genuine love for the people entrusted to our care.

2)  Loving our patients doesn’t mean liking them.  It’s an important distinction.  Loving them, and I mean in a scriptural sense, means doing the right thing because we believe they are also God’s children.  However, we need not agree with (or agree to enable) their choices, life-styles, or anything else.

3)  Loving our patients may mean confronting them.  It may make them, and us, uncomfortable and unhappy.  This may result in letters written to administration.  But speaking the truth will liberate a few from lives they shouldn’t live.  And that’s worth a letter or two in the bad-boy file.  And if it liberates you from a job that wasn’t good for you, well that’s alright too.

4)  Tolerance, in medicine or culture, doesn’t mean complicity.  It means peaceful co-existence.  We’re all perfectly free to try to change one another’s minds, and perfectly free not to change our own.  If I tolerate my patient’s beliefs or attitudes, it does not mean I have to agree with them.

5)  Doing the right thing should never mean doing what we, as physicians, consider morally wrong.  The patient’s desire for my services does not trump my personal ethic or faith.

6)  If I sometimes make a patient, or physician, feel guilty, it’s OK.  Guilt exists for a reason and needs to be experienced now and then.

7)  Uncompensated care is burden we all should share.  No specialist should be able to look like a community hero for being a great doctor, and then send his poor and uninsured to the emergency department to ‘eternally temporize,’ until they can afford his kind ministrations.  It’s not fair and it’s certainly unrealistic.  I don’t want anyone to work for free against their will.  But I also don’t want emergency physicians to be the work-horses of this dysfunctional system.

8)  People who are actively seeking disability for entirely unsubstantiated reasons are among those who should be confronted.  People who can drink, fight, wreck motorcycles and hunt wild-hogs don’t deserve disability.  They need to go to work like everyone else.

9)  Doctors who treat other doctors like slaves need to be confronted with the following words:  ‘I don’t work for you.’  Hospitals who allow this behavior are naughty, and their administrators ought to be ashamed of themselves.  Both of them need to feel guilty, along with those faking disability.

10)  Consultants and specialists have a new rule these days:  ‘If the patient is very sick, transfer them.  If they aren’t, then discharge them.  If they’re in the middle, consult someone else to admit them…like a hospitalist.  I don’t want to come in and waste my holiness on common chattel in the ER.’  The problem is, we shouldn’t be in the middle of this.  I’m a physician, not an answering service.  So are you.  So we need to tell the consultants to come and make their own decisions.  Like playing tag; ‘you’re it!’  And don’t give me that ‘I’ll do you a favor.’  No, you’re doing the patient and the hospital a favor.  So cut the condescension.

11)  Guess what?  People abuse our services.  We have to start setting some rules.  Do our patients realize that if they complain of the same things over and over, year after year, we’ll eventually miss the real problem?  It’s like the little boy who cried wolf, for heaven’s sake!  Is Lortab and a work-excuse really worth the risk to them?

12)  Most physicians have to see patients, and generate bills, to make a living.  Anyone who is paid a salary as an administrator or academic, and whose salary is not tied to patients seen and bills paid, has a good gig.  But they need to be careful about the way they view uncompensated care.  If they’re being paid by the hospital, which is supported by foundations and paid procedures, they should never tell the emergency physicians:   ‘More volume is always good!  Like at Wal-Mart!’  Some volume is definitely bad…very, very bad.

13)  Did that drug-rep pen, or that box of doughnuts, really make me order the more expensive prescription in the face of bad science?  I’ve been entrusted with human lives.  I’ve been trained to make snap decisions involving life and death.  I work all night doing the right thing for some of society’s most disenfranchised individuals.  I argue and cajole patients for their own good and consultants for the patients’ safety.  I risk violence and infections every shift.  I eat fast-food because there is seldom time for a break.  Are you telling me that I’m such a moron, and so morally reprobate, that a pizza and an attractive salesperson will make me throw all my ethics out the window?  I’m insulted.  We should all be insulted by such accusations.

14)  See above.  If you’re a member of a medical board, if you are a board examiner, a member of a quasi-governmental think-tank, a consultant to a political advocacy group or anything else which uses your medical knowledge or position, do you let them pay for your travel and hotel and buy you meals or drinks?  Is it possible that such activities might sway your opinion?  If so, how do you feel about pharmaceutical representatives visiting doctors and giving out note-pads?  If you have any problem with it, look in the mirror.  You just might be a hypocrite.

15)  Most of us don’t mind seeing individuals for free when they need it.  But I wonder, in the current economic and moral climate, do they feel any sense of gratitude?  Back in the old days, a doctor might get a pie or a chicken.  If we see someone for free, then go to their place of business, will we get the same courtesy in a kind of post-modern barter system?  Unlikely.  Why?  We’re rich doctors, we can afford it.  But the problem is, we aren’t and we can’t.  We still have to make a living.  And it isn’t about greed.  Our work and pay support a host of other groups and individuals.  Like our own families and their insurance and education.  And we support licensing boards, malpractice insurers, transcription services, billing companies, nurses, secretaries, etc.  Every membership is $1000 for heaven’s sake!  And every patient costs a fixed amount in malpractice.  We aren’t rich doctors anymore.  We’re financial conduits.  The government can cut us back, but we’ll need a lot of breaks in other areas.  And lots of folks, besides us, will lose money and employment if it happens.

16)  The best care costs money.  A high-end lap-top costs a lot because it’s a good machine.  A BMW costs a lot because it’s an excellent car.  A Sig-Sauer pistol costs a lot because its owner can depend on it.  And health-care, modern, up-to-date, safer than ever, careful, precise, life-saving and life-prolonging will never be the same on the cheap.  Bet on it.

17)  If we think we know a lot, we’re wrong.  In 200 years they’ll scoff at our simple science, our needles and our poisons.  There is so much yet to learn.  And I suspect the great surprise will be the way our minds, bodies and souls are unified entities.  We think we’re so scientific.  We divorce our progressive minds from the ages old wisdom of our ancestors; we believe what we can see, and ignore what we cannot test.  We stumble in the dark, I fear.  What happens when we learn that prayers were more useful in the end than antibiotics?  What will we think when we realize that what we thought was our science was simply the miraculous dressed up in medications?  What will we say when we learn that our DNA encodes immortality.  Don’t laugh.  You might be surprised.

Merry Christmas!  Have a wonderful holiday season.  Stand for the truth and speak it fearlessly!

I’m very proud of you, as always, and proud to write this column.



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