Here’s my column in this month’s EM News on how we’re expected to do more with less…,_Fellow.9.aspx


Preface: I love to write about many things. People, pets, children, family, nature. But over and over I come back to a theme: my colleagues in our specialty and the forces arrayed against us. I’m not trying to be the toxic voice, the endless complainer. But if people like me don’t beat the drum, then nothing will ever change for the better.

In this column I will continue to explore issues of physician satisfaction, I am reminded of a lecture I attended during residency. Let me set the stage. During residency I was also a flight surgeon in the Indiana Air National Guard. This was during Operation Desert Storm, although I was not activated for the brief conflict because I was an intern.

Later in the year I attended a conference of the Association of Military Surgeons of the United States, or AMSUS. One of the lectures was given by a young Navy physician, assigned to a unit of Marines who were armor scouts. They were tasked with driving around the desert in smaller vehicles, looking for Iraqi tanks.

Unfortunately, they were not well equipped as they did not have all of the components for the main guns that might have been able to stop those tanks. They went to a supply depot to obtain necessary material, and were denied the material they most needed.

This physician broke down and cried as he told the story. He relayed emotions of immense frustration. He was unable to obtain medical supplies and the members of his unit could not get the essential equipment they required to fight the enemy, had they encountered Iraqi tanks. Fortunately, the Iraqi army didn’t last long, and thus neither did the war.

Stay with me, I have a point. The frustration I saw on the face of that passionate physician is not unlike the frustration I see, and hear, in physicians around the country today. And nowhere is it more evident than in our nation’s emergency departments.

There are striking parallels between warfare and emergency departments today. For instance, violence is almost expected. Some facilities have metal detectors, some have police officers, but all too many have not even so much as a semi-retired security guard with an ancient can of pepper spray. The danger, some nights, is so real it’s palpable as uncontrolled mental health patients, drug seekers, drunks, gang-members and the various problem children of society all find their way to the unguarded and unarmed emergency rooms of America. There is no recourse, and this is frustrating. Sometimes physicians and nurses feel convinced that the administration would prefer to see them injured or dead than to invest in adequate security or risk the harm of a dangerous patient. (Too much paperwork, you know…)

There are false expectations for the mission. I could write an honest mission statement for most ER’s. ‘Here at General Hospital, our staff is expected to abide by the highest standards of professionalism, compassion and medical knowledge. You, the patient, may curse or threaten them as you see fit and rest assured, the patient advocate will take your side. Our staff is expected to see everyone as quickly as possible (don’t forget our ten minute to doctor guarantee). You may report them if your ankle injury is delayed by someone else’s major trauma. It’s no excuse. Our staff will have you in and out in two hours or less, as often as possible, no matter how poor the staffing or how inefficient the electronic medical records. You, the patient, can expect ice, blankets, fluffed pillows, snacks and satisfaction surveys along the way. Poor staffing on our part is no excuse for delays on yours. Please know that we are very serious about reprimanding clinical staff for even the slightest infraction, in order to maintain your patient satisfaction.’

Like large military forces, emergency physicians and nurses also experience ‘mission creep.’ Our job used to be saving life and limb. Now it’s not only those essentials, but also immunizations, palliative care, psychiatric and social placement, data entry and data capture on a massive scale, endless regulatory comliance and every other imaginable activity wisely shunned by the rest of the 9-5 workaday world.

Likewise, we have confusing rules of engagement. ‘If he’s suicidal, don’t let him leave; but don’t touch him because that’s assault. And if you let him leave you’ll be sued, but don’t keep him in a locked room because that violates his civil rights.’

And like the situation with the young Navy physician and his comrades mentioned above, emergency physicians and nurses struggle with inadequate material and resources. We are usually staffed below necessity, so that we work on the razors edge between competence and disaster. (Nurses and doctors, those ridiculous unnecessary accoutrements of medicine, are expensive. So for goodness sake, don’t hire enough of them; what our facilities really need are more vice-presidents!) Our access to specialists is getting harder and harder. We’re informed that they can’t be bothered, so we must transfer anything complicated to a place where on call specialists are daily overwhelmed by their own under-staffing. Our ability to refer to family doctors is all but gone as family doctors stop taking the uninsured (and those on Medicaid) for quite practical economic reasons.

We are further constrained. We once had free samples to give to the poor, but now we take the high road and have nothing free to give our economically challenged patients. (We’ll show those companies!) Further, good, old and cheap drugs are steadily taken away from us by Black Box warnings and profit motives created by those companies. (I’m thinking of getting some leaches.)

We also are expected to do all of this with the most horrific thing to afflict medicine since health insurance; the corporate addiction to EMR. EMR, billed as a step forward in record keeping, medicolegal protection and error reduction has become an incredible financial boondoggle for those at the top with connections. It has crushed productivity and spirits, and mangled the doctor patient relationship, as competent and caring physicians and nurses are chained, body and soul, to the keyboard, from which their eyes rarely drift to appreciate the nuances of humanity. The keyboard which slows them down, earns them the ire of patients, the frustration of those tracking ‘through-put’ and which routinely keeps them one to two hours after work, for no compensation, to satisfy the corporate and government and administrative over-lords of medicine. Rest assured, if you find an EMR you like, someone will take it away. We can’t have an effective weapon in our armory, can we?

So let’s summarize: violence, false expectations, mission creep, inadequate staffing and resources, unmanageable rules of engagement, too few useful drugs and the toxicity of current EMR systems. Are there parallels to fighting a war without proper support and clear direction? I never went to war. But it sure looks that way to me.

I felt bad for that young Navy Lieutenant. I really did. But I feel bad for everyone who is genuinely powerless to make change in an overwhelming situation. For those who know that their opinion doesn’t matter. Not one iota. Is it any wonder physicians and nurses are at their breaking points?

If there are times you want to cry or scream as well, I say ‘no wonder, brother, sister; no wonder.’

Keep the faith, fellow Emergistanis. I’m proud to fight the fight at your side.

Semper a Decem.

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