Choices

I don't know anyone in medicine who's particularly happy with their career choice. (Okay, maybe the locums neurosurgeon who gets paid five figures per day to sit in a call room and say things like, "Yeah, that's pretty complex, and since I'm not really familiar with the surgical team here you'll better send that along to a referral center." What a deal.) However, nobody will tell you this. It's true that we may have occasional flashes of genuine delight or emotional reward, but most of physicians just gut it out, showing up for work each day, wading through the teeming masses, deferring work as much as we can (translated as "Go to the ER") and wondering why we're not working at a tire store putting tires on cars, because no one is unhappy when they have new tires; or stacking bottles at Liquor Kingdom, because nobody's unhappy when they leave there, either.

It's sad we feel this way because the actual practice of medicine is the easy part. Especially within the vast breadth of issues that come before the ER, there are only so many ways to do things and only so many ways things can go. It's actually very black and white. You're sick or you're not. You're alive or you're dead. You can't be "kind of sick" or "sort of alive." (And you most certainly cannot have fibromyalgia, because it doesn't exist.). Age, race, culture, gender identity, and a host of other characteristics don't change that basic biological equation. There's really not a lot of "gray zone," although that admission puts any number of academics, me in a past life included, out of business.

The Internet is rife with stories about why physicians don't like their careers, and I could list the common themes as well as anyone; administrative hassles, government mandates, insurance nightmares, falling reimbursements, crushing student debt, long hours. (The one they won't list...because it goes against the social narrative that everything is someone else's fault...is that physicians and patients themselves are often part of the problem.). While some of the articles I see are understanding of the physician's plight, most are of the "arrogant doctor deserve everything they get, whiney bastards" ilk. So when people ask me about my enjoyment of medicine...or lack thereof...I struggle with the best way to explain it.

After years of trying to come up with a politically correct solution, I now think that perhaps I don't actually have to explain it. Maybe what I have to do is turn the question into a riddle and let people figure it out for themselves.

In Room 1 is an elderly man with chest pain. In Room 2 is a child with a snotty nose. Room 3 holds a young woman who took an ambulance ride to the ER for a toothache (yes, it happens, and it happens a lot). Who do you see first?

It's an obvious decision, right? The person with chest pain might be having a heart attack. The kid with the snotty nose is just that. So you go and see the chest pain patient, ask careful questions and perform a focused yet detailed exam, take a moment to form your differential diagnosis, place judicious orders into the computer based on your assessment, and document your thoughts into the electronic medical record while the encounter is fresh in your mind.

Meanwhile, the wait time for the kid goes up, and the parents (if there are two parents) become frustrated because they've taken time off work, or away from sleep, or had to pay a babysitter to bring the child to the ER, or brought the other three kids because they couldn't find a babysitter and are now crawling all over the exam rom. Before you even address the issue at hand you're apologizing for delays, and it takes you extra time to not only calm them down, but also to explain how you care for a kid with a snotty nose, because in medicine, as well as in society, we've indoctrinated new parents into learned helplessness. So what could be a ought to be a five minute encounter becomes twenty, which prolongs your patient throughput times. And if you've tried to provide care without a plethora of labs and x-rays, all of such would prolong patient care times, you've decreased your potential reimbursement.

Maybe you can juggle two things at once. Maybe you can have someone quickly show you the EKG from Room 1 to make sure it's not a flaming heart attack, ask one or two questions of the nurse to get the show rolling, and let them start doing things according to a preset protocol whether the protocol is relevant or not. Meanwhile, you duck into Room 2 and get through the kid as fast as you can. It;s an easy case, there's nothing to do for it, and so what if you've not really had a discussion wth the parents? The kid is fine, and time saved. Then you can backtrack to Room 1 and figure out what's really been going on all the time, rolling your eyes at all the lab and x-rays that have been ordered when it turns out the patient's chest pain only happens on Tuesdays. At some point you go back and document both cases in the EMR, noting once again, as you've done before, that it takes exactly the same amount of time to document the care of a kid with a snotty nose or an adult with potentially life-threatening chest pain.

Here's a choice: Maybe you go see the toothache first. It's the quickest to be seen, it'll involve a minimum of charting and paperwork, and since there's no dentist in the ER and you personally don't pull, drill, or fill, it's a matter of a couple of prescriptions and an admonition to go see the dentist. Your average patient throughput time will certainly go down. You might even get a good patient satisfaction score. But if you do that, don't you just reward behaviors that abuse the EMS system and the entire rationale for the Emergency Department? And surely someone will call you back to Room 1 if the chest pain patient turns sour.

Now take this scenario and recognize that in most busy ER's in this country, your average ER physician is responsible for up to twelve patients at a time. And that the toothache (and maybe even the snotty nose), being a non-emergent condition, has probably been seen by a Physician Assistant or Nurse Practitioner, to be replaced on the doctor's agenda by something like abdominal pain, vomiting, vaginal bleeding, migraine headache, fever, possible injuries from a motor while accident or a fall in a nursing home, overdose, psychiatric crisis, or chronic pain, all scenarios in which it's incumbent upon the physician to do something to make sure there's no actual emergency, but not do too much to take up too much time or generate an excessive bill. All the while navigating family dynamics, patient expectations, social needs, clinical disposition, and appropriate pain management with the inevitable negotiations that accompany them all.

(As an aside, our ER has started giving out cards that list the Patient Advocate's phone number as part of our discharge paperwork. Not a bad idea, I suppose; if people have questions about their care, or their bill, they ought to have someone to call. But when you read the card it says to contact the Patient Advocate if you have "concerns" about your care. Nothing there about compliments. Which lets you know exactly where the Patient Advocate, as well as Administration, stands in reference to doctors and nurses. Words matter.)

It's an extreme example, of course, but it serves to illustrate the point that emergency medical staff (and, to a lesser degree, all health care providers) are working under a set of inherently contradictory mandates that are plain to everyone involved in patient care but are absolutely invisible to those in the corporate suite: The belief that you can, with no changes in resources and increasing patient loads, have faster greeting times, faster turnaround times, higher billings, and higher patient satisfaction, all at the same time. (Quality of care is an afterthought, and if there's a problem it's time to come down on the physician, for the hospital is not in the practice of medicine and it's simply not right to recognize any pressures or mandates the hospital might put upon the physician as contributing to any errors that might be made.)

I've had good bosses and bad bosses, but just like you can pull some valuable lessons out of a bad relationship (which is why I like sushi and know what an eyelash curler is), my worst boss did teach me something that I still think holds true. (Personally, I think he was an idiot, so I assume he got it from somewhere else and was able to read it off an index card.) It's that in health care:

(Access) x (Quality ) = Cost

Working through this equation, recognizing that access is a "people" number, quality is whatever we happen to define it as at the moment, and that cost is not always counted in dollars but can be counter in time or lost opportunities, it's clear that the paradigm that all things are simultaneously possible is fatally flawed.

Let's say that the number of patient being seen ("access") is flat, and improved patient satisfaction is our measure of quality. We know that time spent with the patient is the prime determinant of patient satisfaction. Patients want to move through the system, but they don't want to feel part of an assembly line. So using the equation, increasing patient satisfaction necessarily increases throughput times. We also know that another determinant of patient satisfaction has to do with the amount of care provided in terms of testing and prescriptions. If that's our measure, then costs in dollars rise.

If we want to decrease costs, ether as dollars or time, something else has to go. Each provider needs to see less patients (decreasing the access number) or patient satisfaction must fall. This is true even if we use (heaven forbid) true quality of care as defined by clinical metrics as our outcome goal. It's health care stoichiometry. It needs to balance.

I don't know the right answer, other than I don't think there is one. I would say that good clinical care is the optimal outcome, but within policy and administrative circles that is clearly no longer the case and that horse has long ago left the barn. There can, in fact, be no right answer when your goals are at odds with one another. What I'm hoping is that someday someone far above my pay grade will actually admit, in a nod to Spandau Ballet, that they know this much is true. But I have no confidence that this will occur before even more physicians and nurses, exhausted and burned out, become mere wage earners trapped in their jobs rather than the caring and compassionate professionals most of us wanted to be.

No, there's no right answer, at least not one that I, as an individual physician doing patient care, will ever be privy to. The Administrator du Jour, or the Administration du Four-Year Term, will decide what the right answer is for now, and undoubtedly one component of the answer will be that the providers are just not doing things right. Policies will be written, institutions will undergo "culture change" and "rebranding," metrics will be compiled, and a couple of months later we'll be back where we've started, with administration spending great whopping gobs of cash and rewarding themselves for non-existent accomplishments and providers feeling once again disheartened and disillusioned. No matter how many times you rearrange the deck chairs on the Titanic, the ship still goes down. And while those on the top decks are offered first place in the lifeboats, those in steerage...your doctors and nurses...are locked behind iron grates below decks and left to drown.

Bar Mitzvahs and Bomb Shelters

Being a parent is truly the greatest thing ever. I love my kid like nobody’s business, and I suspect most parents feel the same way. It’s true that The Teen drives me nuts in more ways than I can count (and I’m certain he would say the same about his father), but the real frustration is in seeing your faults repeating themselves in your child. He and I were talking about that the other day, one of those pre-dawn chats you have when you come home early on a night shift and inadvertently wake up the kid, when he’s not sleepy enough to tune you out but no so awake that he heads straight for his computer. We talked about the things he does to get in his own way, and I talked about mine. It seems like laziness…or at least the ability to be easily distracted into things that are not productive…is one of my unfortunate legacies.

As I get older, I find I’m much more comfortable with confession and admitting my faults. Maybe this is the insight and wisdom that comes with age; more likely, it’s finding excuses for not being all I could have been, shrugging off lost opportunities based on based on bad habits I can’t break the same way the patient with end-stage lung disease says they can’t give up smoking…and since they’re at the end, why bother now? But I think it’s true that I could have done a lot more in life if I didn’t get lazy.

Here’s an actual example of what I mean, ripped from the pages of my life just this past week. When I get home after work, I should be working out so I don’t wheeze after going up two flights of steps, or so dedicated to the frustrated writer inside of me that I would be willing to scribe on a TV tray like Stephen King used to do before Carrie. What I actually do is eat either two bowls of Apple Jacks or, if I’m feeling adventurous, make French toast. Then I watch an “on-demand” episode of The First 48, yelling at the screen the whole time (“Nail that perp! Nail his a__ to the ____ing wall!), then hit the channel guide and realize that I can’t stay awake long enough to watch “The Big Valley” on MyTV. I then retire to bed with my iPad in hand and find that I’m looking up The Big Valley, then Miss Barabra Stanwyck, then Richard Long, then Nanny and the Professor, then back to Barbara Stanwyck again, then off to Double Indemnity, then Fred MacMurray, then My Three Sons, off to Tina Cole, to the Four King Cousins (four You Tube videos as well, loads of hairspray everywhere), then the King Family, next the King Family Specials on PBS, then Mr. Rogers, and finishing up with searches for Joe Negri. Robert Trow, Francois Clemons, and Betty Aberlin. Then I’m not tired anymore so I play an hour of Fishdom. And by now it’s too late to take a melatonin to get to sleep, because I’ll wake up with a hangover, and I’ve totally missed the episode of The Big Valley that I couldn’t stay awake for three hours before.

(Incidentally, if you’ve not seen “The Bitter Tea of General Yen,” a 1933 film with Barbara Stanwyck and Nils Asther, it’s well worth a look. Obscure now, but daring themes for the time. And don’t get the new Fishdom game, “Dive Deep.” I hate in-app purchases to get to the next level. Just tell me how much to pay for the game and let me play.)

So as I’m talking to The Teen about those things in life that get in our way, I mention to him that while he has unquestionably inherited my wit, charm, good looks, and above all modesty, he’s also got my tendency to be distracted and lazy. As I’ve noted before in these pages, he wants to be the next Roger Ebert, and he unquestionably has the talent to do so. But I’m trying to explain to him that this means you learn to work on a deadline, not just when the flash of literary inspiration hits you. He, of course, rightly points out that I’m just as bad. So he and I have worked out a deal. We will require each other to blog at least once a week. If he doesn’t come through, I get to choose a costume that he must wear throughout the four days of GenCon, the largest gaming convention in the world. (I’m thinking Fluttershy of My Little Pony). If I don’t…well, he’s trying to think up an appropriate penalty because, as he says, “You have no shame.” No, I don’t, not where embarrassing my kid’s concerned. It’s a Dad thing.

Brendan’s entry this week is a review of 10 Cloverfield Lane. (It’s brilliant. Please take a look at The CriticalFrog.blogspot.com.) But as Brendan is a true movie buff, able to place films in context with genres and styles, when I see a movie my mind usually does what it does with my iPad before I go to sleep, wandering from topic to topic with no particular focus in mind. So my thoughts on the movie generally center around the fact that the lead character (played marvelously by John Goodman) is named Howard, which is my name as well, a point The Teen continually reinforces with veiled suggestions that perhaps I should build a bomb shelter in the backyard.

(For the record, I have no intention of building a bomb shelter in the backyard. This is not because I have great faith, as does every pageant contestant since Eve duked it out with Lilith, in world peace. It is because I’m certain that one of my fellow doctor friends whom I know has a guest room in his house will take my in, and that his home has enough tinfoil lining the walls to stop them from reading our thoughts and enough weaponry to keep us all alive throughout the Zombie apocalypse and then some.)

Howard’s not a great name. Never has been, but at least I know how I wound up with it. It wasn’t a deliberate act on my parent’s part to keep me in comic books and dateless until my early 20’s (I did that to myself.) It’s a Fiddler on the Roof kind of thing. In Jewish tradition, you usually try to hand down part of a name of the most recently deceased relative, which in English usually translates to using the first letter of the first name. So when my great-grandfather Harry Burgheim married a woman named Hennie, and they had a son named Harold, the die was cast. My Mom was a Harriet, I wound up a Howard, and my brother is another Harold. And two generations hence, when we’re gone, another crowd will wind up with “H” names and wonder why their parents hate them, too.

Just as Christians often get confirmation names, we also have Jewish names. You usually get this at a bris or a naming ceremony as an infant, which is why no liberal Jew has any idea what their Hebrew name really is. These are also usually passed down from deceased relatives, but not quite as literally. For example, your name could be Bob (and mine is Bob every time I got to someplace that asks for my name on an order, because I’m tired of telling people how to spell “Howard”), and your late great-grandfather’s name could be Fred, but if his Hebrew name was Yitzchak yours likely will be too.

As I’ve mentioned, nobody really knows their Hebrew name unless it’s the same as their actual name (think the ultra-orthodox in New York, where I understand the name Pinchas, with a guttural “ch”, really get the ladies going). This came to be a problem several weeks ago at my nephew Thomas’ bar mitzvah. Before I go any further, I need to say that Thomas did a magnificent job, even though somehow in his speech he forgot to thank his best uncle on the planet for his support from afar, which may or may not manifest itself in an acute deficit of Channukah presents this year. But I digress.

During the ceremony, different members of the family are called to the bimah (the stage in front of the sanctuary) to recite blessings over the Torah before it is read. You get called up to do the blessings by your Hebrew name, which was a problem because neither Brendan nor I knew our Hebrew names. Fortunately, Judiasm is nothing if not a creative religion (we came up with that whole monotheism thing), so we were assigned Hebrew names by the enterprising rabbi of the Joliet Jewish Congregation. I became Avigdor ben Yussel (“ben” means “son of,” and my Dad’s name, Joseph, does translate into Yussel), and Brendan morphed into Efron ben Avigdor. It could have been worse. My Uncle Steve got the alliterative Schmuel Yuel ben Matisyahu, and my nephew Thomas wound up with Tovia Fivesh Meir ben Shoshana, which sounds like…well, I don’t know, but probably something that doesn’t go down well on Tinder.

I didn’t particularly like these names. So I wrote my sister, who was actually in charge of the festivities (she’s a Jewish woman; did you really think anyone else would run the show?), that I wanted a different Jewish name. I wanted mine to be Moshe Dayan, and I thought Brendan’s might be Harpo Marx. I was told that changes this year were not an option, but that I might be able to make a case for next year at my niece Lauren’s ceremony. I’m still holding out for Moshe Dayan, and I have an eye patch ready to go. But I think Brendan may opt for something from Yu-Gi-Oh or Pokemon (Charizard ben Charmander, I choose you! Gutteral “ch”s all around.)

(Incidentally, this rabbi was great. Had a wonderful speaking voice, moved the service along…which matters when you’re the child of parents who always went to the early services on Erev Yom Kippur and Rosh Hashonah because they knew the rabbi had to get up to speed to be able to clear the house for the late show…and was really a lot of fun. He would ask us to “kiss the torah” with the edge of our prayer shawls in the voice of Sebastian the Crab from The Little Mermaid. This made me laugh out loud, much to the dismay of an old man who shushed me from under his rainbow-striped tallit that looked like something on the box of Lucky Charms.  This rabbi also plays dodge ball:  "I never get to throw things at the kids in the synagogue."

Oh, and in the Sibling Rivalry Department, I should mention that while my brother screwed up his blessings, I got mine right. I did so well, in fact, that another little old guy came up to me at the reception afterwards and wanted to know if I was a member of a synagogue. When I told him I lived out of town, he engaged in that well-known game of Jewish Geography, noting that he had second cousins in Kansas City and did I know them? He also wanted to make sure that I was going to take The Dental Empress to Israel. For her part, The Empress was a trooper the whole weekend, especially when confronted with a bowl of chicken liver…“Try it first and I’ll then I’ll tell you,” was my Mom’s response to her inquiry about its’ nature…and she was very understanding when Dad said she was welcome in any of our pictures, but I’d better not do something to lose her because he was tired of cutting the heads of my ex-wives out of family photos. This is the same father who has given his blessing to this relationship, as opposed to my priors, because, “this one comes with a house and a job.”)

It also turns out, unbeknownst to the family in advance, that if you’re over 13 and called to the bimah to perform the religious duties of an adult Jewish male, it counts as a bar mitzvah of sorts, a recognition that through your participation you’re accepting the obligations of an adult Jewish man. So in addition to the bar mitzvah we thought we were attending, there were four additional “drive-by” bar mitzvahs that morning between myself, my brother, my Dad, and The Teen. Which was pretty cool considering that we didn’t have to go to Hebrew school, we got to read transliterations of our blessings, and we got to sponge off someone else’s reception.

But back to 10 Cloverfield Lane. Bottom line: It’s got a Howard in it. He’s a creepy survivalist with a bomb shelter and tub of acid in the backward. Howard is a crappy name. It’s mine, too, which means for the foreseeable future I’m going to hear an endless stream of 10 Cloverfield Lane jokes. But at least I used to be Dan Conner, Geln Allen Walken, Walter Sobchak, and King Ralph, and at least one of them is Jewish. Could be worse. And as I’ve said, I won’t be building a bomb shelter in the backyard. I’m just lazy.

"Bags of Stuff": ACEP 2015

You may have heard about changes in the marketing practices of pharmaceutical companies.  It’s now considered unethical for companies to offer, or for physicians to accept, gifts from manufacturers of drugs and medical devices.  The theory here, of course, is that physicians who get stuff from these corporations are more prone to use those drugs or devices regardless of efficacy or cost, driving up health care expenditures without necessarily benefiting anyone but the purveyors of fine pills and nostrums.

In all faith, I cannot say that I’ve never been influenced by a drug company.  I’ve written before in the pages about how, on a small scale, I still know the dose of a currently obscure antibiotic because during my internship a salesman for this drug brought my fellows and I donuts every single day for a year.  And in the heyday of pharmaceutical marketing, when I had become an attending physician in the early 1990’s, I went to Boston for a weekend on someone else’s to learn about clotbuster therapy for heart attacks.  (Yes, the other person’s money was the company that made the drug.)

Personally, I miss those days.  Not because I think I was corrupted by the process, but because in an era where the practice of medicine and respect for physicians has been knocked so far off it’s pedestal that we’re like the shattered bust in the end credits of Peabody and Sherman, it would be nice to be flattered once again.  So yes, I’d like to be influenced by the drug companies. I would happily take their money to support research.  I would beg to be one of those players known as a “drug whore,” doctors who get shipped to meetings both at home and abroad to present lectures on important topics such as Reversing Anticoagulants and then get to say things like, “There are three agents out there.  I’m going to talk a lot about one, very little about a second, and none about a third,” and then claim to be an impartial evaluator of the literature.  Bring it on.

However, the simple fact is that emergency physicians are relatively insulated from that sort of marketing.  The reason is basic economics.  We don’t do anything particularly profitable.  With some rare exceptions, what we do is pretty basic.  We don’t use expensive antibiotics or symptomatic medications, especially as much of our clientele couldn’t afford them if we did.  Because we have short clinical attention spans, we don’t prescribe high-cost, long-term maintenance medications.  Even most of the IV medications we use have been around for long time, and while there are some medical devices we use they’re rarely the innovative, costly, single-use, high-volume supplies used by our colleagues.  It’s not that we can’t use them; it’s that we don’t need to in order to be the Great Triage Officer of Life and Death.  So there’s very little money in pushing expensive blood pressure medications or coronary artery stents to us.  We simply just don’t use them.

That doesn't mean we don't get "marketed."  There are some pharmaceutical and medical device companies who bring their wares to display. But it's mostly from physician recruiters, individual physician groups looking to by pass the recruiters' fees, and locums agencies trying to find part-time docs to go to places that nobody can recruit for.  There are risk management groups, billing firms, places that outsource documentation, scheduling, and practice management.  All of them say the same thing and use the same words, most of which end in "-ize" (optimize, maximize, incetivize), which is Latin for “make the galley slaves work.”  So how do you stand out among the competition?  The answer, of course, is the trinket.

Here's my disclaimer.  Trinket acquisition is one of my primary drivers for attending medical meetings.  The education tends to be spotty unless you happen to know a particular speaker is really good. I'm not a networker.  Most of the receptions are way too crowded, and most "open bars" really aren't.  But I am totally enamored with the scavenger hunt through the exhibit hall, to see what I can pick up and then leave in a large tote bag for whatever housecleaner enters my hotel room after I'm long gone.

Like any game, however, you have to know the rules to play:

1. You may take only take one of each item from any one exhibitor.
2. As long as you don't have to talk, you may feign interest in anything.
3. If you are required to talk, you may not lie.  For instance, you may not say you don't want to practice in dusty East Texas because you're afraid the cat's allergies will start to act up.  ("But it’s not like that! We have hills and trees! Watch our video!" exclaims the lovely Miss Longview 2012.) You may, however, invoke fixed personal characteristics as an excuse, as when dealing with recruiters for hospitals in the oil-rich sheikdoms of the Middle East ("I'm not sure my people do so well there.")
4. If you don't know what something is, you have to ask so you can accurately record it.

Record it, you say?  But of course.  Getting the stuff is only half the fun.  Then you get to take it back to the hotel to sort through it, and catalog in detail what you've obtained.  (This is best done while eating room service spaghetti and watching Los Reales in Game 1.)  Then you compare it to your previous catalogs to get a sense of how medicine has really changed.  It's a faster, quicker, and much more accurate way to look at medical progress than any old textbook or lecture.  

With this as background, I'm pleased to report to you my gleanings from the 2015 Scientific Assembly of the American College of Emergency Physicians in Boston.  Here we go:

Eight plastic boxes of band-aid strips.  Each box contains five band-aids.  I have never really thought about how many band-aids I use, so I don't know if this is enough for a week or a lifetime supply.  I have resolved to monitor my band-aid use in the future as part of my own personal Customer-Focused and Culture-Changing Continuing Quality Improvement project. (I've been looking for an excuse to work all the hot administrative buzzwords into a sentence.  Bingo.)

One golf towel.  I think it's a golf towel, because it has a little grommet in it and some kind of clip. I don't play golf.  But if I did, I'm not sure what message it sends that I'm wiping grime onto your product's name.

One ice scraper.  This is from some very nice recruiters for a hospital system in Southern Illinois. I actually suggested to the Cream Of Collinsvile that if you're wanting people to move there, reminding folks that they're going to have to chip snow and ice from their car may not be the best pitch.  In retrospect, though, I think maybe they got it right, because the other selling point would be "We're really close to East St. Louis."

A full-size selfie stick.  Here’s the story.  Last month the Dental Empress and I went on a Mediterranean Cruise.  As we wandered the streets of the Old World, we learned that the Official Street Vendor Product of the European Union is the selfie stick.  So at lunch one day outside the Colleseum we fell into a discussion with a British couple sitting next to us and a Spansih foursome sitting one table over.  The latter group had been drawn into negotiations with a street vendor (who, I’m fairly certain, was not a native of the Tiber River Valley) over the cost of a selfie stick.  The initial asking price was ten euros.  Then it went down to seven, at which point the Brits noted that they had bought their selfie stick in Venice for only three euros, in a fine example of free market economics.  The final price was four euros, or a little over five bucks, accounting for the difference in the cost of living between the capital and provinces.

(The British couple, while great company at lunch, were truly a mismatched pair.  He was a young, very quiet IT professional, while she was an older, extroverted marketer and outdoors enthusiast.  They were describing how their first vacations together were disasters until they hit on the solution to spend their holidays someplace where neither of them will be particularly happy.  Which is why they’ve spent two weeks in each of the last three years at a hermetically sealed beach resort in Egypt.  Which plan, as of this writing, probably needs to be rethought.)

Thirteen different sizes and shapes of tote bags, of which I'm planning on keeping two.  One is from Long Island Jewish Medical Center.  It's really of very high quality, with zippers and a shoulder strap and quite subtle advertising for a give away item.  It's also of sturdy fabric, which you probably need while using the bag as a weapon to fight off the thugs which this boy from Flyover Country is convinced lurks behind every corner of the New York Tri-State Metropolitan Area. And yes, I cognitively know that at Long Island Jewish Medical Center I'm more likely to encounter an elderly matron selling raffle tickets for Hadassah, but they scare me, too.  The other bag I'm keeping is an insulated lunch bag forma healthcare management company, because helping  me carry my lunch is about the only thing a healthcare management company will ever do for me.

Two refrigerator magnets, one of which gives me the warning signs of atrial fibrillation, which might be helpful on those days my heart skips a beat when I find those forgotten "science experiments" in the back of my refrigerator. The other says, "Dammit  Jim, I'm a Doctor, Not a Data Entry Clerk, " which is silly because everyone knows the Data Entry Clerk is Yeoman Rand.

One round plastic pizza cutter.

Six 2 GB flash drives.

Four of those things that you plug into your car's cigarette lighter, into which you then put a USB cable, and then plug into your phone to charge it more slowly then you burn power listening to Spotify.  I don't actually know what they're officially called.  Car charger sounds wrong because you're not actually charging your car, and you need some other pieces like a USB cord to charge anything else.  I do know you can usually find them in plastic buckets for $3.99 near the check-out of the Quik Trip, which means they're probably made in China for less then a nickel apiece, which lets me know just how much those who peddle these promos think of me

Eleven different sizes and shapes of bottles of hand sanitzer, all of which could pass by the TSA as they are all less than three ounces in volume.

Four buttons that say "I love night shifts;" a further button modeling the Flag of Emergistan (a buzzard on a field of red, green, and blue); and a badge from a company called Blue Jay Consulting that says "Be Happy" that I picked up just so I could look at it and say, "Not so much.  Go Royals."

("Emergistan," the Land of Emergency Room, is the creation of Edwin Leap, MD.  He's an excellent writer, and has the gift for finding positives in the chaotic void.  From a literary standpoint, he's the good child you want to live next door, while I'm that distant relative you have to invite for the holidays, and why you serve Thanksgiving dinner at 10 AM so you can move him more quickly out of the house.  Catch up with Dr. Leap at edwinleap.com)

A plastic slinky.

Ten plastic foam squishy toys, incldung three ambulances, one gold key that won't fit anything, three balls, a blue and gray fish, a yellow van with the VA logo, a rhino., and a football.  

Two toothbrushes, one in a fold-up plastic travel case.  One box of floss shaped like a tooth.  A bicuspid, if you must know.

A rubber duck with a stethoscope and that head thing that doctors are supposed to wear that I've never actually seen a doctor wear.

A faux leather mini football that seems tough enough for actual play. In contrasting this to the squishy football, the good one is from a company in Texas.  Which makes snese, because people in the south take football seriously.  The promotional football is not a toy.  It's a lifestyle.

9 diferent collapsible coozies, two of which are bottle-shaped.  There was also one rigid cylinder shaped coozie which was used to great effect as I put a brown glass bottle of cream soda (yet another giveaway) inside it, totally covering up the label of the latter and giving the impression that I was swilling my way through the exhibit hall...an impression which, truth be told, I did nothing to correct.

16 different computer screen wipes.  Most are simply wisps  of cloth, but one looks like a soft furry green sea urhcin, or perhaps an inverted Scrubbing Bubble.

Seven containers of chapstick.  Four tubes, three plastic balls.

Three stuffed animals. The two bears wearing promotional tee-shirts show great promise as dog toys.  The Snoopy dressed in World War I Flying Ace gear is mine.

Eight plastic sleeves that I couldn't figure out until it was explained to me that you're supposed to stick them to the back of your cellphone so you can put your driver's license and your credit card in there so you can keep them all together and eliminate the need for a purse or wallet when you go out.  it also means that when you lose  your phone, you can suffer identity theft and have your credit ruined as well. I was also told that once you stick it on, it's nearly impossible to get off. I can't use them myself, because I already have an "I Was Brave" sticker featuring Thomas the Tank Engine on the back of my phone from when I got my flu shot last year and didn't pass out. (I've got a thing about needles.) 

Seven small notebooks, including one from a US-Saudi joint venture with Arabic script on the cover which will go down beautifully with the TSA. Out of this assortemnt, I'll be keeping a small red one that look like Chairman Mao's.  I plan to paste fortune cookie papers into it and quote them frequently in a cryptic yet knowing way.

One small travel package of Kleenex.  Why only one, you ask? Because there's no crying in ER.

Three letter openers with covered blades, because death by an unsheathed letter opener is just silly.  

Seven different lanyards with clips for ID badges, so you have seven different ways to declare your corporate allegiance. (Disclaimer:  My ID badge lanyard at work is form Princess Cruises.)

Two large plastic squeeze bottles, two medium-sized rigid plastic cups with built-in straws, one travel cup, and one "shaker" from a vendor in Hawaii that i was told is to be used to mix up protein shakes and the like, but that I will keep becuase I thnk it would be somehow fitting to make tropical drinks for sitting poolside in a cup sponsored by the Aloha State.

Six large magnetic clips you put on your refrigerator to hang up your children's drawings.  Only one of them is big enough to use as a chip clip.  My son is way past the refrigerator art gallery stage of life.  So you can guess which one I'm keeping.

(Shameless promo:  The kid doesn't draw, but he does write.  Check out his blog at thecriticalfrog.blogspot.com.)

Lots of candy.  And lots of little plastic packages of mints that I might maybe someday use as placebos. But when I do, I'll give them a fancy name, like Obecalp.

A sewing kit, which will prove to be of no use to me as I can sew a screaming kid, but cannot fathom things like what buttons are or how they got there.

Eleven small flashlight, presumably for looking at small things.

One tee-shirt that says, "This is Your Brain on ICD-10."  (Okay, you had to be there.)

Two yo-yos, which may also be used as bolos to hunt small game in a survival setting.

One collapsible travel cup.

Three miniature harmonicas on key chains.

Two plastic wishbones.

One squishy blue rubber ring and one similarly textured clear rubber ball filled with lots of smaller pink, green, blue, and yellow balls. Both of these blink incessantly when squeezed.  

One retractable tape measure.

Two sets of fake teeth that you can put between your lips.  When you blow into a small mouthpiece, a small fan creates a whirring sound.

Three gel packs that I can freeze or heat as needed to provide pain relief when my Dilaudid runs out.

Badge ribbons.  If you've been to large meetings lately, you will have noticed that the recent trend is for attendees to stratify themselves through the ribbons they attach to their name badge, things that say "Director" or "Board Member" or "Donor" and the like.  (I think these are the convention equivalents of fifty-five year old men who drive fire-red sports cars, the rainbow of markings on the amorous mandrill, and male peacock feathers.  An evolutionary biologist would have a field day sorting out this competition for status, not to mention the fertile females.  Or maybe it's a more innocent behavior, sort of like a certain Labradoodle I know named Goldie Goldstein who will fling her 70 pounds of dog at your head, landing with a resounding thud , eyes open, mouth agape, tongue lolling, drooling everywhere, as her saliva-punctuated way of proclaiming, "Pay attention to me!"). In response to this trend, there were several vendors giving out additional ribbons with some less important mesages, including "Troublemaker," "I Run With Scissors," "I Read Your E-mail," and of course "My Ribbon is Better than Your Ribbon."  I got a buch of those last ones.  Two went on my badge so the fertile females would look at me more than those one-ribbon guys.

A small lapel pin of the Canadian flag.

A 3.7 ml bottle of tabasco sauce, whch I look forward to using in its entirity on one medium sized tiger shrimp.

116 assorted pens, all fairly nondescript with the exception of one shaped like a femur and another that has  wobbly jack-in-the-box head with strands of blue yarn hair on the top.  84 write with black ink, the remainder blue.

A rubber device that looks like a plastic pocket protector with an attached  megaphone.  What you do is slip this over the end of your iPhone 5 and apparently an opening on the inside of the pocket is right over the speaker, which then transmits the sound through the megaphone to the world at large.  Which is probably a great thing, if you have an iPhone 5 and have a background in cheerleading.  The Dental Empress is a former cheerleader (all four years, cheering football and basketball, not wrestling...I understand that's important in Cheer World) so I know what a "Herky" is, and I'm currently enamored with the "Cheerleader" by OMI but that's as  close as I get.  Plus, I went right from an iPhone 4 to a 6 because the same cheerleader told me the 5 was awful, though in retrospect it probably just needed a megaphone.  And yes, on this one I had to ask.

That's just the trinkets.  I did actually look at some products as well. More on that later.  Now, If only I could find a pen...

Truth or Consequences

With the Big Ball Drop now nine full months behind us, it seems an appropriate time to consider some New Year's resolutions.  One of mine is to tell the truth.  That may seem like a no-brainer to most people, but that’s sometimes been hard for me.  Frankly, I’ve not been the poster child for honesty in some of my relationships.  I’m on the right road now, and finding that truth-telling, while sometimes painful and requiring quite a bit of verbal gymnastics to say what I want without collateral damage to those I love, is a whole lot easier that digging yourself out of whatever pit you’ve fallen into.  Only took 25 years to figure this out, but at least I’ve finally got it right.

That being said, this new veneer of veracity also forces me to admit that I lie like a dog at work. I suspect all ER docs do, even if we don’t admit it to ourselves.  I’ve been thinking about the lies we tell and trying to discern a pattern…translated as “I’m switching from nights to days and can’t sleep…and I’ve decided that our lies can be grouped in a manner similar to Maimonides’s Eight Ascending Levels of Charity.  (Maimonides was the greatest of the medieval Jewish Philosophers, living in Spain and North Africa during the Twelfth Century.  He was also physician to the Sultan Saladin, which just goes to show that everyone wants a nice Jewish doctor).  So as the most minor Jewish philosopher in Shawnee County, I’d like to propose the Four Descending Steps of ER Lies.


One Step Down:  The Lie of Obfuscation


These are the common, everyday lies; the ones we tell by shading the truth in a way that keeps us out of trouble.  How can a doctor or nurse get in trouble by telling the truth?  Perhaps you missed the memo, but medicine today is not driven by the provision of great care and the occasional “hard love” that’s required to change patient behaviors for long-term health.  No, my friend, it’s driven by customer service and customer satisfaction, by the need to grab and secure your market share, and doing anything that jeopardizes that…like telling a patient an uncomfortable truth in a way that puts their continuing patronage at risk…can be a dangerous game for the unwary physician who suddenly finds himself on the end of a patient complaint.  “The customer is always right” ethos has become so fixed that when the patient is upset the doctor is presumed guilty, and the only way to prove his or her actions were appropriate is by documenting the more egregious behaviors of the patients.  Every patient encounter becomes potentially adversarial from the start, and as most ER docs in this country work for someone else rather than part of their own group practice and so are considered interchangeable cannon fodder, every patient interaction is the one that can generate the complaint to get you fired.

You may think this is an over-reaction.  But I cannot tell you how many times in over two decades of doing this that I or my colleagues have been accused of racism, sexism, homophobia, ageism, Medicaid-ism, socio-economic classism, and just plain rudeness.  And why?  Because on occassion we try to tell people the truth.  We explain that they are obese, and they are responsible for their own diabetes, arthritis, or chronic pain.  We tell people there’s nothing we can do for them unless they stop smoking crack or drinking alcohol.  We remind people that it’s irresponsible to miss appointments with their primary care doctor or not take their medications, especially when we’ve built a safety net system specifically to meet their needs.  and while most folks understand and accept what we want to say, there are those who at best have an adverse relationship with the truth.


(Speaking of racism, I really enjoyed the guy who came in late one night in Western Kansas full of himself, as well as a few toxic substances.  He was abusive to all, and as the local gendarmes were assisting his disposition he called me a racist.  “You’re right,” I said, the full glow of my Caucasian pigment shining upon him.  “I hate white people, too.”)


So the Lie of Obfuscation occurs when you’re trying to communicate a message in a way that won’t get you an e-mail the next day.  Let’s take the aforementioned hefty individual complaining of chronic back and knee pain, which you know will never get better until they drop the poundage.  But instead of saying, “You have this pain because you’re fat and you need to lose weight,” you say, “You know, you’re kind of a bigger person, and that might be part of your problem.”  Technically, at 6’1” in a nation where the average male stands 5’9 ½”, I’m a bigger person.  I also weigh 150 pounds after a box of Twinkies.
 
Here are some other examples:


Truth:  You have asthma and you smoke.  What’s that all about?”
Lie:  “You know, smoking in the midst of your asthma attack is not such a good thing.  Would you like me to tell you about that?


Truth:  “This is the fourth time you’ve been here this month for your (choose one or more) chronic pain, fibromyalgia, alcohol abuse, drug abuse, mood disorder.  At this point, there’s nothing we can do for you and this is a waste of both our times.”
Lie:  “We’re always happy to see you and evaluate you for an emergency medical condition. Fortunately, there seems to be none present today.”


Truth:  “You tell me you don’t have a doctor, but every time you’ve been here you said you had an appointment.  Then the next time you’re back you say you missed it.  What’s up with that?”
Lie: “It can be difficult getting to see the doctor.  We’ll make another referral for you today.”


Truth:  “Your doctor (or the Ask-A-Nurse phone line, or Poison Control) is a moron.”
Lie:  “Fortunately, there’s nothing serious going on.  And those lab tests and that MRI and that elective surgery your doctor sent you in for is just going to take up a lot of time and cost a lot of money, and I don’t think it’s something we need to do tonight.  I think everything’s going to be just fine.  Glad to help.”


Truth:  “I’m not giving you any pain meds because I’ve looked at your medical records and the term “drug-seeking behavior” is all over your chart.”
Lie:  “I’m sorry, but people have expressed concerns about your use of narcotic pain medications and I’m afraid I have to honor those concerns.  It’s also not my practice to write prescriptions for chronic pain in the ER.”


Truth:  “I know you’re going to drink.  Could you at least do it at home where, when you pass out, nobody will call the cops and the ambulance?”
Lie:  “I’d like to offer you the chance to go to detox to help with your drinking.”


Truth:  “People who really want to commit suicide don’t call their ex-boyfriend/ex-girlfriend/ex-wife/ex-husband/parent/child to let them know.  Here’s a pamphlet from the Hemlock Society.”
Lie:  “I’m glad you called for help.”  

(Closely related is the Accessory Lie of Withholding, also known as Applying the Internal Filter.  Examples including not telling patients they are aesthetically displeasing oxygen thieves, their babies are ugly, that they really should have sprung the extra dollars for the good tattoo parlor, that the only good genitals are unexposed genitals, or that they are piss-poor pieces of protoplasm  that, through their very presence, make a convincing argument against Intelligent Design.  This is also the one where you don’t say to the patient on public assistance bitching and threatening to refuse to pay, “You’re not paying for it anyway.  I am.”  The inability to consistently tell the Accessory Lie of Withholding is probably why I work a lot of night shifts, out of the daytime presence of Administration.)

Two Steps Down:  The Lie of Feigned Ignorance

Doctors, nurses, and other health care people know a lot.  Most of that which we know we tell you.  We may tell you in a way that’s fun for us, especially if it’s juicy stuff.  For example, if your urine tested positive for methamphetamine after you had told me you don’t do drugs, I could just walk into the room and say, “Your urine has meth in it.”  That’s boring.  Or I could sit down and say, “Just remind me.  I think when I asked about drugs, you said you didn’t do any, right?”  When you confirm that statement, then I get to say, “Well, your urine tested positive for meth.  How do you think that got in there?”  Then I get to watch you come up with a story.  One of the better ones lately involved a woman who was pretty sure that some guy named Peabody was using her bong last week to smoke meth and must have left some in there when she was smoking her weed the next day.  (Fair warning:  The excuse “I was holding it for someone else in my hand, and must have gotten in my skin,” doesn’t work.  Neither does “secondhand crack.”)  This is an especially fun conversation if there are others in the room, for if they are there I assume you’re okay with them hearing everything I have to say, else you would have shooed them out.  This works especially well with positive pregnancy tests and the diagnosis of STD.

Most often, though, the things we don’t tell you are bad.  If you show up in the ER with three weeks of turning yellow, a twenty pound weight loss, and no abdominal pain, I can tell you without any further ado that you have pancreatic cancer and things will not go well.  (If you don’t believe me, look up “painless jaundice” on the Internet School of Doctoring, which is always right according to patient when I disagree with their research.) If you show up like this, I will get a CT scan on you, and it will show a large mass in your pancreas where it meets the bile ducts draining the liver, and more likely than not your liver will look like a piece of swiss cheese from all the areas of metastatic tumor in it.  But when I tell you the results of the scan, I will not tell you that you have metastatic cancer and bad things are going to happen.  I will instead tell you that you have a mass in your pancreas, blocking up your liver, and that while I don’t know what it is we’re going to need to put you in the hospital to figure it out.  Similarly, if you’ve recently had a biopsy and I can find the results in the computer, I will probably not tell you what they are if bad.  If I’ve done a procedure known as a thoracentesis, and the fluid that comes out of your chest cavity is bloody, that’s cancer.  I won’t tell you that, but I know.  If there’s an infection raging through the frail body of your elderly parent, I’ll say that her condition is serious and we’ll do all we can to help.  I won’t say I know she’s going to die.

It’s not that ER docs aren’t able to give bad news.  We do it all the time, especially when death happens suddenly, and are probably so fluent with it that it seems rehearsed. (Which, by the time you’ve done this a while, it kind of is.  What changes is not your speech but how the family reacts and what you do then.)  We also don’t mind asking about Living Wills or Do Not Resuscitate Orders, because they directly influence what we do in the ER.  But when it’s something like cancer, or overwhelming infection, or an incapacitating stroke, we often don’t have very many answers for what is likely to be asked.  You hate to add more fear by not being able to provide knowledge or solace.  And I truly do think the definitive diagnosis is best delivered by someone who will follow the patient and be part of their continuing care.  The lie may be explained and possibly even justified, but a lie nonetheless.

Three Steps Down:  The Lie of Caring 

Unit Clerk:  “Good morning!  How are you?”
Doctor:  “Just happy to be a part of the healthcare system of the Citizens of Northeast Kansas.”


Here’s the dirty little secret.  When it's busy, when people are demanding, and when nothing seems to be going right...which are more days then we care to recount in a hectic ER...we don't have time to care about you the way we should.  We go into a mode where we care more about what’s been emphasized to us by administration as the benchmarks of success.  Moving you through the system.  Treating you in a way that you won’t make any fuss.  Getting your paperwork right.  Eliminating liability.  When I walk into the room and say, “What can I do for you?” during those times, what I often mean is what can you tell me so I can get you out of my ER, and off my hands, as fast as possible; or alternately, what can you tell me that is going to mean you stay for a long time and jam up one of my assigned rooms so I don’t have to see as many patients?  And if I'm able to do that in a way that allows me to truly care for and about you, that’s just icing on the cake.  

Does this mean we never care?  Of course not.  Here’s a tip:  Show up with a real illness or injury.  Look sick.  Have something happen to you that’s beyond your control.  Don’t drink and drive, get beat up, or puke. Have cancer.  Have a stroke, a heart attack, or trouble breathing.  Be a child.  Quit smoking, lose weight, and take your medications as directed. Don't use me as your primary care physician for chronic problems, and then get angry when I can't fulfill your wants.  Understand that I'm working as fast as I can, and accept my apologies for delays in your care. Recognize that when you’re old, you’re going to feel weak and dizzy and fall and there’s nothing anyone can do about it unless you break a hip, and then all we can do is fix the hip but not the weakness and dizziness.  (I personally think the back of every AARP card…including mine, acquired for discount movie purposes at the tender age of 51…should be stamped with the message, ”If you are over 75, you will feel, weak, you will be tired, your joints will ache, you will get dizzy, and sometimes you may fall.  You’re old.  It happens.”)  Deal with your own angst.  If you’re over 30, don’t bring Mommy into the room and get her to talk on your behalf.  Don't lie to me.  Respect the nurses.  Stop texting.  And be pleasant.  Smile.  If you do, you’ll find that all the caring we’ve been building up not caring for others will wash upon you like a tsunami once you have something genuine for us to care about. It doesn't take all that much.

Four Steps Down:  The Lie of False Hope

At the end of life, or in times of critical illness of injury, all the tools are in the hands of the physician.  The only thing the patient has left to work with is hope.  Hope that they’ll get well, hope that the medical system won’t fail them, hope that their deity of choice will see them through, hope that their friends and family will be there with them as they go into that dark night. The Lie of False Hope is to give hope where there is none.  It is the most heinous thing I think I do in the ER.  I believe that one should have time to prepare for death with the mind uncluttered by extraneous promises or guarantees.  What makes this lie worse is that often the patient knows that you’re lying, but accepts what you say in an effort to postpone contemplating the inevitable.  The English savant Dr. Samuel Johnson has been quoted as saying, “When a man knows he is to be hanged in a fortnight, it concentrates his mind wonderfully.”  Do we not owe it to those in the last weeks, days, or moments to allow them to concentrate on the experience of life at it’s fullest just before the fire dies?

Why, you may ask, is this worse than not caring?  Because as long as the patient thinks you’re going to do something for them, they can handle the fact that they are nothing but a task to you.  But to give them hope where there is none, so death comes as surprise; to pretend your efforts will mean something when you know they will simply result being seen to do something?  Playing the game of Medical Theater is the worst lie of all.

At long last, that’s the truth.