This is my column in this month’s Emergency Medicine News.  In Medicine, Atlas endures.  For now…

Most modern American are familiar with the classic political novel, Atlas Shrugged.  Love or hate it, the novel had a great impact on political thinking in the West.  If you haven’t read it, or aren’t familiar, one of the fundamental questions author Ayn Rand asks is this:  what if the producers and innovators of society simply stopped trying?  What if they became tired of contributing and being abused, demonized and taxed for their efforts, and simply withdrew their contributions?

Atlas is straining in medicine as the weight of contemporary healthcare continues to fall upon  emergency departments and as increasing numbers of physicians in other fields either retire or escape from call duties.  I don’t necessarily say this by way of critique.  I understand the perspective of those who have, quite reasonably, made tactical withdrawals from the losing battle.

We face fewer available specialists.  Drug shortages are rampant.  Psychiatric beds are a rarity as state budgets plummet.  Committees and professional societies heap volumes and volumes of new rules on the practitioners of medicine, as if it weren’t difficult enough.  And yet, at the end of the day, the answer is typically:  go to the emergency room; they’ll sort it all out.  And we are full, overwhelmed, understaffed, underfunded and overextended.

So what if we took a cue from Atlas Shrugged?  What if, in one grand, unified effort, emergency physicians decided to stop doing their work, if only for a day?  Or what if we all found another permanent way to earn our incomes?  What if we said ‘no’ to further satisfaction surveys, endless psych holds, innumerable Medicare regulations and pointless JCAHO visits?  If we refused to be fined for not washing our hands every five seconds, if we said ’15 minutes to a doctor’ is ridiculous.  If we explained that blood cultures didn’t matter for most patients and that we were finished giving thrombolytics for stroke when we felt it was the wrong thing to do? What if rule-makers and fine-givers and policy-writers were stuck, for just one day, sorting through the madness that was born of unfunded mandates and unintended consequences?  What if we just said NO!

Well, like that game we all play called ‘what if I won the lottery.’  It’s all academic.  That is, an Atlas Shrugged moment would be a very unlikely event.   For one thing, we aren’t organized enough.  For another, we couldn’t replace our incomes (and therefore pay our debts and bills), that easily…or that quickly.  In addition, we generally dislike change and we have a wonderful, awful habit of following orders and doing ‘the right thing.’  It’s what got us into medicine.  But it’s also what will keep us there far beyond reasonable levels of endurance.

However, another reason emerges.  We feel a sense of duty, a sense of obligation, to the patients who come through our doors.  No matter how bizarre or difficult the work, we press on and do it.  At all hours of the day and night, we station ourselves between patients and death, between patients and disability (no matter how much some of them want it!) and between patients and suffering.

I realized the dedication of my partners and staff recently, as I watched a drunk ‘patron’ pick up his walking stick and pull it back to hit our security officer, even as a deputy politely said, ‘excuse me,’ pushed his way past everyone and fired a Taser into the stick-wielding gentleman.  He dropped fast and was hauled away to the law enforcement center in handcuffs.

I realized it a few months ago when an angry psychiatric patient, who had a ‘sitter’ while he awaited placement, picked up the sitter’s laptop and smashed it through the clear plastic window around the nurses’ station.

My stories are mild compared with some of yours.  You face violent gang members while I more often face obnoxious drunk Southerners.  Many of you face illegals with drug resistant Tb while I am scalpel wielding warrior facing MRSA abscesses by the bucket.  I sort through rattlesnake venom and Xanax overdoses while some of you face designer drugs of no known origin, composition or effect.

Of course, we do it all professionally.  We do it the best way we know how, with fewer and fewer resources.  We do it with falling reimbursement and increasing regulatory burdens.  We do it day and night, holidays and weekends.  It lacks the glamor and gloss of sexy doctors on television shows. It falls short of the moral clarity actors, and politicians, seem to bring to modern medicine.  It is murky and difficult, even on the best days.

Our ‘office’ is the place of chaos.  An administrator once told me, on a day of terrible crowding and dangerous volume, that he couldn’t move patients upstairs to the hallway.  His reason was this:  ‘Dr. Leap, when people leave the ER, they expect to go to a better place.’  I walked away, unable to speak.

Outside of law enforcement, EMS or the military, what work-places are like this?  And who would face such things with regularity even as their reimbursement was cut, their threat of lawsuit ever-present and their every move regulated and watched as if living on parole?

Atlas, at least in medicine, isn’t likely to shrug off his duty.  Oddly, we love what we do even as there are days we despise it.  But that’s a pretty frightening ‘what if.’  All of the senators and congressmen could walk out tomorrow and we’d experience little more than a sudden burst in economic activity.  Most of the attorneys could do the same and our litigation would remain gridlocked…like much of it is already.  But some things matter every day of the year.  Gas has to be refined and pumped.  Cars, buses and airplanes have to move people and material.  Electricity, along with water and food, has to be available.  And disease and injury need to be treated.  And even Atlas needs some relief; needs to make a living, needs to pay his bills.  For Atlas, at least in our profession, the ‘honor and glory’ of carrying everything is wearing off.  And yet, Atlas endures.

What am I trying to say today?  Well, it’s Thanksgivings this month, so here’s a reason for thanks.  America should be thankful that emergency departments are open, and that they are staffed around the clock by well educated, dedicated professionals who don’t shirk their duties.

And thankful that they so far haven’t shrugged off the enormous weight that daily rests upon their broad shoulders.  America should pray that they never do.

If Atlas shrugs off healthcare, it will be a dark day indeed.

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