The Problematic, Disposable Criminal, er, Doctor

This column was inspired by my attempts to be credentialed in other facilities as a locums physician.  I’m not bragging, but I have darn good credentials and a very clean record.  And yet, at every turn I felt as if I were an incarcerated felon asking for work-release. And over the years, as rules have mounted, I always get the sense that an army of individuals with rule books is just certain I’m a loose cannon.  We’re making medicine worse and what physicians really need to do is reassert our primacy in the profession.,_Disposable.6.aspx


I wonder, sometimes, are physicians valued professionals, or merely problems to be solved?  Are we skilled clinicians vital to the well-being of our patients?  Or are we merely assetts to be managed?  It occurs to me as I walk around hospitals these days, and see the overgrowth of people with clip-boards, people with undue authority over our lives and practices, people trained in business and management but untrained in either the science or art of medical practice.

I ask because I see the struggles of many good clinicians, who are beset by administrators (who are themselves beset by rules and threats from federal and state overseers as well as various groups like JCAHO).  Granted, there will always be a few docs who need re-direction.  But we should be doing it, instead of leaving it to those who really don’t understand. Ultimately, however, the things done in the name of corporate compliance or patient satisfaction or any of the dozens of other new catch-phrases are done in a manner that seems to see physicians as wayward children, or at the as worst felons just looking for a chance to commit their great crimes.  We are often treated as if we are on some preemptive parole.

In some instances, the problems stem from patient complaints and customer satisfaction issues.  The problem, as I’ve stated before, is that the customer satisfaction model does not move easily from retail America to Medical America. When applied in our hospital emergency departments the ‘customer’ is often unreasonable, rude, profane, threatening or has inappropriate expectations.   But this is then transformed into a scenario in which the physician (or nurse) who cared for the customer must have been the problem.  It is interesting to see the clip-boarded staff desperately trying to make excuses for the drunk, the addicted or the simply rude people who slow down care and thereby make life unpleasant for the medical and nursing ‘commodities’ in our departments across the land.  They always seem a little confused when we explain that these customers never pay anything into the hospital. They have one paradigm and shifting from it is simply impossible…unless the entire industry shifts.

I even saw this at work after our facility had a an event in which a mentally ill patient assaulted, and very nearly killed, a nurse and injured several others.  The committee meetings that followed were sometimes comical, as administrators sat wringing their hands over whether we needed cameras or more security; and over whether or not police officer should be allowed to have weapons in the ED.  (We can’t have a dangerous customer being shot, it appears.)

In addition to being ‘problematic’ and ‘disposeable,’ physicians are now viewed with significant suspicion.  The amount of oversight and regulation of our profession is staggering.  Hospitals have multiple employees and committees, multiple ‘watchers,’ to track credentialling, complaints, compliance with regulations and quality of care.  They are forever keeping data, keeping charts, logging the time till the patient was seen, the time till the patient was discharged, the time till the CT scan was done or read, the time till the ECG was ordered and interpreted.  They bring us forms and show us files and remind us over and over that we are under scrutiny.  They check the charts and take us aside.  ‘I need to discuss this with you…,’ sometimes in the midst of our busy shifts.  I realize that some of this is driven by the Joint Commission or by the feds via CMS.  But that doesn’t mean hospitals and their administrations shouldn’t make compliance as easy as possible. And it doesn’t mean that they can’t give feedback to the higher powers about the utility or difficulty of these measures.

Not only so, we have enormous higher oversight.  We have assorted board exams in medical school and residency, then specialty boards which reasonably ensure our competence.  We have background checks and state licenses and state and federal narcotics permits.  We have background checks and fingerprinting to obtain those licenses.  When applying to new hospitals or states we need references and more background checks. We have to demonstrate that we have been continuously employeed and give the dates and contacts.  They tsk, tsk over even one lawsuit, even if it had been years before, as if any error were an indicator of a higher character flaw.  It all may seem fairly benign to those outside of medicine. But from where I sit, it all feels onorous.  It all feels as if I’ve done something bad, and need to be watched carefully by teams of trustworthy, diligent nurses and managers.

But what bad thing have I, have you, done?  In emergency medicine especially, we have worked long and hard to be trained, and we have spent days, evenings and nights frequently treating the poor and destitute, the drunk and addicted in addition to the gravely ill.  Much of our care has been given for free.  We have been available holidays and weekends.  And we have done it all while trying to please the customers and respect our managers.

Our efforts, our struggles, our life and death, day and night lives sometimes make it a little difficult to be endlessly monitored and judged, evaluated and vetted by those who are unavailable after hours, or in the midst of violent assault and terrible tragedy.  Evaluated by those whose days move from meeting to meeting, punctuated by lunch and paperwork at the desk, and upon whom no one is imposing rules that say:  ‘You know, you had ten minutes to finish that form. You went beyond ten minutes and I’m going to have to start documenting your progress. If you can’t do better, we may need to consider hiring someone else.’

Our collectively well-demonstrated dedication to the practice of emergency medicine, and medicine in general for our colleagues in other specialties, makes it galling and demoralizing to know that from every angle, from every organization, at all hours of the day and night, we receive more oversight than the average criminal.  In fact, I have cared for any number of patients who were injured while driving under the influence, only to find that they had multiple previous convictions pled down to first offense. For us, it feels as if there is no plea-bargain.  Only another file kept in another office.

Increasingly, as in much of regulation driven America, our crimes, our errors, will seem small to us, but enormous to the ‘machine’ that is the modern hospital.  They will have to do with things already mentioned.  Time to EKG, time to PCI, time to CT, time to documentation.  They will be issues of documentation, and screening and of doing all the things that eventually roll down to emergency physicians and nurses from the rest of the world, but with time-limits attached.  They’ll will be issues of patient satisfaction, which will be tied to reimbursement.  They will all happen in what will continue to be the endlessly chaotic world of the ED, where there is never a limit on who can come in, or how many can come in and never a limit on what we are asked to do, for patients, consultants and administrators.

I understand.  There are rules and regulations.  And someone has to implement them.  But there are too many of them, and clinicians need help and support more than increased distrust and oversight. There are bad doctors; I get it. But most are good and need to be treated and valued as such.

I don’t want to spend my career feeling like a criminal, or like a form to be filled-out, a problem to be managed. I want to spend it doing the job I love and do so well, which is caring for the genuinely sick and injured.

Dear administrators and politicians, regulators and all the rest.  In the words of my surgery resident during medical school:  ‘Help me, don’t hurt me.’

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