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.

The Doctor's Dilemma

At the start of every shift I go through my e-mails. I find it a nice way to ease into my workday, and it's sort of fun to count the minutes you spend reading e-mails, multiply it by the amount you're getting paid per minute (and make no mistake, every ER doc knows what that number is), and realize you've just made money by clicking on announcements of new hires you'll never encounter, seminars you'll never attend, and the administrative glad-handing that passes for the aura of employee relations.  I could tell you that I'm looking intently for updates on clinical policies and care pathways that will lead to improved patient outcomes, or opportunities to fulfill  my educational needs, but the truth is I'm looking for Nastygrams.  Those are the e-mails that start out with some variation of "Remember that patient?" Any written communication that starts this way is by definition bad.  In the ER world, good news is handed out in person, while bad news is always in writing (to cover everyone involved except the proposed offender).

 

(You can also use the “I know how much I’m making per minute” theory when you’re doing personal tasks like going to the bathroom.  I like to think about it when I’m fetching the patient some water or juice.  It takes me two minutes to walk across the ER, open the refrigerator, get the juice, fill a cup from the ice machine, find a straw and a lid, and take it back to the patient, drag a tray over to the bedside, open and pour…yep.  Just bought lunch.)

 

The Nastygrams come in several varieties.  The primary one is the Patient Complaint.  The patient disliked something about what you did or didn’t do, and the Patient Advocate (now there’s a neutral job title) and other Administrative Poobahs would like you to review the chart before they confirm your anticipated guilt.  If that sounds alarmist, it needs to be understood that one of the current paradigms in health care is that the customer (patient) is always right, no matter how that plays out against the backdrop of clinical care.  It’s all about the satisfaction scores, about seeing the patient quickly, about making sure they’re happy during their stay and leaving with a positive impression so the patient, family, and friends will continue to seek care, and bring their dollars, to this hospital.  Which is all well and good, and something to be pursued, until you recognize that a lot of medicine doesn’t involve making people happy.  It’s about doing the right thing and the right time within the limits of your abilities and resources, and as often as not it means doing what might not be considered optimal customer service.  And if the scores come in low, no matter what the reason, it’s the physician who’s on the hook because otherwise it’s a problem with the system, and that might implicate the folks in suits.

 

Once you review the record, the complaint is usually not a surprise; and if you've done your documentation correctly (including direct quotes from the patient of phrases that rhyme with "brother ducker," "whole mitt," and "brass mole"), the Cubicle Dwellers have no choice but to reluctantly send a letter to the patient apologizing for the hard feelings, but regretfully concluding the care was appropriate. (The line, "It was documented that you acted like an orifice, and our staff was exactly right to send you on your happy way," is apparently not part of the template.)

 

(Speaking of which, my colleagues and I recently got an e-mail from one of our Medical Directors complimenting our group on the fact that there had been no patient complaints in the  prior two weeks.  I sent back a note and explained that I was on vacation.)

 

The “customer service” mantra leads to a strange and costly practice of medicine, where tests are ordered simply to be doing something or to meet patient  expectations, drugs are dispensed to make patients happy or simply because the doctor isn’t up for the fight (I think every ER doc has experienced their own version of “Give’em What They Want Wednesday,”), and the time needed to fully understand what’s going on with a patient, to set realistic expectations for the ER visit, and to provide good explanations of diagnoses or discharge instructions is truncated by the need to deal with those complaining more loudly and threatening to leave.  (I’ve never quite understood why, when someone wants to leave the ER because they’re not being seen fast enough or they don’t like the care they’ve received, we need to fall all over ourselves to get them to stay.  They are self-triaging themselves back to the community despite our legally-obligated offer of care.  Isn’t that what we want people to do…to take control of their own health care?  Yes, unless their departure means less revenue.)

 

If clinical correlations mean anything…as they rarely do in the world of customer service…there are studies that suggest that more “satisfied” patients actually get worse health care and experience worse outcomes.  And what’s more interesting is that those very things you can do to enhance customer satisfaction…like taking more time with patients to provide teaching and explanations, making sure family and friends are involved and informed, and going through discharge instructions carefully and completely…work against the goal of enhanced patient turnaround times. (More on that later.)

 

Which leads us to the Nastygram by the Numbers.  I truly do think it's a welcome development that an increasing amount of medical care is judged by objective criteria.  For example, if we know that patients should get certain medications after a heart attack, and that old people should get influenza and pneumonia vaccines, it makes sense to keep count of how many actually get the recommended care.  These are objective, specific, and measurable criteria proven to show a benefit to patient care.  The problem is that many other criteria we're judged on, especially in the ER, are totally abstract numerical goals without any clinical basis or demonstrated outcomes.  Many of them are promulgated by what I think of as the "Center" industry, which are those organizations set up to certify institutions as a Stroke Center, a Chest Pain Center, and others of that ilk for a healthy fee.  Which ultimately is not a clinical designation, but a marketing one.  (Ever notice how no hospital markets itself as a "Methamphetamine Center?"  It's because the bean counters don't want those folks...perhaps better termed as "non-revenue clients"...darkening the door of their ER.  Strokes and heart attacks mostly involve old people with Medicare, which means payment. Meth intoxication?  Not so much.)

 

Despite the fact that these criteria have no basis in reality, when one of them is not met the Nastygram follows.  For example, many have heard of "clotbuster" treatment for strokes.  The theory goes that if strokes are caused by small blood clots that limit blood flow to the brain, these medications get into the vessels and blast these clots away.  The catch is that you have to give these medications under four hours or so from the onset of the symptoms of stroke; beyond that time, the risks of life-threatening bleeding from use of the drug outweigh any benefit you might see  The criteria is that once the patient arrives in the ER, you have an hour from the moment the patient walks through the door to give the medication.  If it's given after that first hour, or there's no reason on the chart why you didn't give the medication (not everyone qualifies and it's not universally indicated), you "fall out" and your e-mail inbox fills.

 

Why one hour?  Nobody knows.  It's a totally abstract number.  Nobody has ever been able to quantify how much brain tissue is lost between 59 and 61 minutes.  And while I would surely agree that quicker treatment times are generally better, sometimes you need to take the time to discuss with the patient and the family the risks and benefits of treatment, and the speed of their decision process often does not match yours. They may want to talk to additional family members, or you may simply have problems finding anyone to talk to.  Maybe you need some lab work to make sure the patient actually qualifies for the drugs, or simply time to get the story straight so you know what you're doing.  And it's worth noting that in a recent study of Certified Stroke Centers, the majority were unable to meet their own select criteria for administration of the agent in less than an hour.  Rather than citing unproven numbers with the force of law, wouldn't it make more sense to track your own facility's times, come up with a goal, and look for roadblocks in the process rather than to come down on individuals for falling out on criteria that clinically means nothing and can't even be met by the best of hospitals?

 

(And this is even without addressing the very real clinical argument that the drugs may not be very useful overall, and should not even be considered the standard of care.  Once again the “Center’ industry…no doubt supported by the pharmaceutical folks who make these drugs…has promulgated a standard that may not even reflect the best practice in patient care.  This is similar to what happened with the standards for cardiac resuscitation over a decade ago, where a perfectly useful and inexpensive drug called lidocaine used for irregular heartbeats was magically replaced by a much more expensive and less useful agent called amiodarone, and nobody could figure out if there was a connection between the maker’s kind and generous support of the American Heart Association and its’ Clinical Investigators, and the change in standards.  But I suppose this is all cyclical and really nothing new.  At one time I understand it was popular to be a “Leech Center” as well.)

 

The most recent “quality benchmark” has been proposed by the Department of Health and Human Services.  HHS has set a goal of getting patients who will be discharged home in and out of the ER in a total time of two hours.  They’re even talking about it being used as a reimbursement factor.  Let’s leave aside for the moment that this is a totally abstract number, and that even the fastest doctor in our ER group did an experiment one month and couldn’t get her patients out in less than 120 minutes no matter how hard she worked.  Given unlimited resources of staffing, scores of empty patient rooms, and idle x-ray and laboratory machines just begging for something to do, you could probably meet the goal.  Nobody has that, and the two hour turnaround for all discharged patients often becomes a totally unobtainable measure in any busy ER that can’t be met without tricks of accounting (and there are ways to do that, some legitimate, some not so much).

 

But the practical issues beg the question of whether meeting this goal represents a measure of quality, at least as defined in medicine.  Fast turnaround times are possible, as long as the patient has a straightforward outpatient problem, sufficient ancillary resources are available to permit rapid lab and x-ray evaluation, and the physicians and nurses are not otherwise burdened with an  excessive number of patients under care or even a single critical patient which can take them ‘out of the system” for a prolonged period of time.  But that’s most often not the case.  As an emergency physician, the nature of the work means I’m not fully dedicated to a single patient at a time, and I can’t focus on moving that one patient through as quickly as I can.  I’ve got up to ten or more patients to juggle at a time, all with different issues, different levels of severity, and different agendas and expectations that need to be resolved.  Statistically speaking, the conflict is really one of modeling ER flow.  Throughput goals are based on a linear model of patient arrival, departure, provider workload, and client movement through the department.  Patients being the subjective and unpredictable creatures that they are, those with “boots on the ground” recognize that the ER actually works on a non-linear model.  Patient show up when they choose or need to, have varied complaints, require different levels of clinical and social interventions.  Workload for physicians and nurses follows a non-linear pathway as well.  So turnaround times mean something, or nothing, depending on who you ask; and as a result it’s hard to have a coherent dialogue with between two mutually exclusive perspectives.  And while shorter turnaround times no doubt promote customer satisfaction, it’s an open question whether that is equivalent to quality care, which brings us back to where we started.

 

Then there’s the Nursing Complaint.  As the power of Nursing Administration (who represent the majority of "critical" employees) within the hospital structure grows, the relative power of the physician ebbs.  It's fine when the paternalistic (at best) or authoritarian (at worst) physician-nurse relationships of the past become collaborative in nature.  But the pendulum has swung so far that the relationship is often adversarial, with the doctor considered guilty until proven otherwise.  Nurses are considered rare prizes and hard to get, and hospitals commit to specific staffing ratios and promotional schemes to keep and retain them; physicians are thought of as interchangeable commodities, especially in this era when most ER docs work not for themselves, but either as hospital employees or for an outside staffing group whose bottom line is profit margin and keeping administration happy.  So who becomes your more valuable asset when conflict occurs?  Especially in the ER, where physicians provide no referrals to the hospital, do not expand the financial footprint of the facility, and don't generate outside revenue for the institution?

 

(I'll be the first to admit I have little to no internal filter at work.  But I always watch myself when I talk to nurses, especially if I disagree with their assessment or they've made a blatant error in care, because I know who's going to win that argument.  It's not me.)

 

Don't misunderstand me.  It's not that doctors don't act like jerks from time to time. They do, myself included, and some of us more often than others.  And we've all done things in a moment of confusion of exhaustion that good nurses have caught and helped us correct. When these behaviors become routine, we should probably get called out on it, and in practice we do.  But since nurses are "owned" by administration in a way that doctors aren't, they're routinely protected despite similar behaviors or a frank lack of knowledge. 

 

(Want to know something else that really annoys me? Anonymous complaints.  We're professionals.  I'll sign my name to my concerns if you'll sign yours as well.  Otherwise, we both lose the opportunity to confront each other in search of the truth, and to find accommodation between our views.  Or better yet, just ask what I'm doing and why I’m doing it in real time.  I really don't mind questions, and an ensuing discussion if you've got a different point of view. But let's act like adults here, okay?)

 

Finally, we come to the Billing Questions, the subject of the most recent Nastygram to collect dust on my electronic desk.  It concerned a lab test for hepatitis, and I was asked by the billing office why I ordered the test.  The way the billing process works is that anything ordered needs to link up to the discharge diagnosis according to established criteria (the “criteria” industry is yet another moneymaker.)  If the test does not relate in a predetermined way to the discharge diagnosis, no payment for that test is forthcoming.

 

I went back to the chart to find out what occurred.  The patient presented with a probable cellulitis, or skin infection.  He had also come in with instructions from his doctor to be tested for HIV, the virus that causes AIDS.  He wanted this test done, and clinically when I test for HIV I also test for hepatitis, which is also transmitted through blood and body fluids (and which you are much more likely to contract from exposure than HIV).  They run together in high-risk individuals, so it always made sense to me think that if you’re at risk for one, you’re likely at risk for the other. And wouldn’t you like to know in advance rather than be surprised one day when you wake up looking like Chiquita Banana? Isn’t that good medical care?

 

But according to the Billing Lords, with a diagnosis of cellulitis the test not indicted.  So here’s the dilemma.  We’re told that medicine is now all about customer service, and I’m doing what both customers (the referring physician and the patient) want done.  I’m probably helping to secure a referral base by honoring that doctor’s request, and hopefully the patient will provide a glowing report back to him or her.  But in the effort to enhance customer service and provide quality care I've run up a charge that can’t be billed, and in getting these extra tests I’ve probably increased my throughput times.  I’m caught either way I turn.  And none of these issues which come to haunt me in the Nastygrams involve the actual provision of care for the patient’s skin infection, which is to prescribe some antibiotics, advise the patient to elevate and apply warm compresses to the leg, draw a marker line around the area of redness to make sure it doesn’t get any worse, and wish the patient the very best of the afternoon. 

 

In reading back through what I’ve written, I seem like nothing more than an angry old coot.  There’s truth in that.  I am highly frustrated with the current practice of medicine for any number of reasons, but for the record I don’t object to being judged in my work.  I simply want the standards to be fair and to mean something to clinical practice and patient care, which should be my bottom line.  And I want the playing field to be level, to know that my word means something, and to know that the institution for whom I work is actually on my side.  I’ve been in places where the hospital declared open war on physicians; fortunately, that’s not the case where I practice now, and I hope the tide doesn’t turn until I’m ready to hang it up for good.  But that spectre is always out there, and all it takes is one new administrator in just the wrong place to tip the balance…as it inevitably will.

 

Thanks for reading.  I’m sorry it’s taken so long today, but I’ve been busy writing other paragraphs.  I really appreciate your patience and understanding.  Please be sure to fill out your customer satisfaction survey.  Please make sure you rate me as a “9” or “10,” because anything else is considered a failure.  If you like me, the name’s Dr. Rodenberg.  If you don’t, it’s Dr. Smith.  Because we don’t have any of those here in our ER.

"Fire Phasers, Mr. Grant!"

We've all had the problem of songs getting stuck in our head.  I've noticed, however, that the problem seems to be more acute as I get older, and I think this is because as my short-term memory fades, I can no longer recall any recent tunes that involve anacondas and buns and the like, leaving large gaps in the mental day needing to be filled with retained television theme songs from the 1970's, mostly from The Love Boat, which echoes through my head constantly anytime I'm on a cruise ship, much to the total chagrin of The Teen, who, whenever he sees a cute girl on the ship and his father notices his interest, is likely to have that same father spontaneously break out in a chorus of "Love!  Exciting and New! Come Aboard!  We're Expecting You!" in off-key but most enthusiastic baritone which will hammer at his adolescent brain until he's run down the nearest staircase and the sound cannot penetrate the deck plates. Which is why, as The Teen and I ventured to the frozen North this past week to partake of the opening weekend of the Minneapolis-St Paul International Film Festival, all I've heard since I got off the airplane were the musical questions of Who Can Turn the World On With Her Smile and (you're way ahead of me) if She's Gonna Make It and, because I am a hormonally addled male nearing the end of my days of non-chemical enhanced potency, with whom, and how often.

(For the record, Minneapolis and cruise ships are not the only places this happens to me.  My brother lives in Cincinnati, and I cannot see his phone number pop up on my cell without asking myself if anyone wonders whatever became of me.  Similarly, when Ii was in Seattle a few years back, I spent half the time trying to match up the gray urban landscape and overcast sky with Bobby Sherman's descriptions.  I also spent a considerable amount of effort trying to find the iCarly building, but that's a different story.

I've not known much about Minneapolis.  There's the Mary Tyler Moore show, of course.  There's the Minnesota Vikings, the Minnesota Twins, and the late lamented Most Appropriate Hockey Team Name Ever, the Minnesota North Stars.  I know Bronko Nagurski was a Golden Gopher.  And snow.  Lots of snow.  So it was admittedly with a somewhat narrowed point of view that I arrived in the Eng Bunker of the Twin Cities and headed directly to The Mall of America.

At first glance, The Mall is breathtaking in its vastness.  (It's the only mall I've ever seen that has its own train station and attached $250/night hotel.)  I'm sure most people have heard something of it.  There is an indoor amusement park complete with roller coasters, a ferris wheel, and a log flume.  There are movie theaters, a bowling alley, a miniature golf course, and more shops and kiosks than you can count.

But once you get past that first impression of sheer size and scope, it dawns on you that it's still a mall.  Writ large, of course, and all contained within a nondescript concrete bunker to keep you warm while you do your destination shopping in the depths of December, but still pretty much just a mall with stores you can find anywhere else (although it is interesting to note that because the place is so large, there are sometimes two versions of the same store located at opposite ends or on different floors).

Remember Mary's tune that kept going through my head?  It didn't stop at The Mall. So as I'm looking through the Minnesota souvenir stores (of which, including local crafts, sports, and college memorabilia, I recall at least nine) and I'm finding myself strangely drawn to Goldy the Gopher, who seems so much more cute and cuddly and, well, mascoty, in comparison with the Chickenbird who lives thirty miles east of my house, the Kittycat who lives 45 miles to the west, and the Angry Dancing Wheat two hours to the south, but I am finding no Mary Tyler Moore show trinkets at all. I would have bought a light blue WJM blazer and done homemade podcasts with the news, I really would have.  But alas, I'm too old for consumer culture, and instead the stores are full of natural goods and healthful candies and homespun clothing and things featuring moose instead of aerodynamic tam-o-shanters or the Sue Ann Niven cookbook or t-shirts that proclaim "I HATE SPUNK!  Guess all I can do is grow with the times.  Which is why I now own a necktie shaped like a walleye.

There was one place in The Mall where the MTM theme was replaced by another, and that was at Star Trek: The Exhibition. Several years ago I had seen a Star Trek installation in Las Vegas, and was quite impressed.  I arrived at The Mall too late to go into the exhibit that night, but was able to visit the gift kiosk which, in contrast to the embarrassment of Trek riches I had seen in Vegas, was comprised of not much more than a few shelves of plastic phasers and communicators, one each of a Lt. Uhura and and a Lt. Sulu commemorative plate, and some of the requisite yellow, blue and red tee-shirts.   I did break down and buy a set of Star Trek cocktail glasses and a red leather wallet that, when you open it, has the words, "He's dead, Jim" embossed on the pocket (I'll explain it to you later.)  However, I was not willing to part with nearly seventy dollars for a cheap imitation of a medical tricorder that purported to say multiple phrases but only spouted (you guessed it) "He's dead, Jim."  It might have been fun to take to work if it said a few other things, but I've found that people who are not dead generally don't like to be scanned and told they are, and those who are dead already know it and scanning them is really redundant.

As I said, it was a pretty skimpy gift shop, and I was concerned that the exhibition itself would follow suit.  But ever the optimist, I bought my ticket anyway.  And not only was I was surprised at how much fun I had, I was even happier that The Teen, who knows William Shatner more from a bad rendition of Bohemian Rhapsody than as James T Kirk (or TJ Hooker, or Denny Crane...but trust me, he's being educated) had a blast.

At this point, I need to issue a disclaimer and note that if you're not into the World of Star Trek
or, even worse, one of those people who prefers a universe peopled with fictional furballs like Ewoks and Wookies, and whatever the hell Jar-Jar Binks is, rather than the ABSOLUTELY REAL Hortas, Talosians, and Gorns, you are going to be bored silly and wonder if your $16.95 entrance fee could have been better spent on...well, anything.

But if you are of that world, it's a 90 minute slice of heaven.  It starts out with a timeline of space travel, starting with Robert Goddard and moving through Zefram Cochrane, The Treaty of Khitomer, Voyager, and Deep Space 9.  There is an original Captain's Chair from the Enterprise-D and, more interestingly, one from the Enterprise-B, captained by Ferris Bueller's friend Cameron (don't make me explain this).  There are original costumes (was Shatner ever really that short and thin?), and an occasional set dressing where I found myself involuntarily bent over a recreation of the Engineering console on the Enterprise-D, trying desperately to bring the warp drive back online...even though I'd much rather be working alongside my childhood favorite Montgomery Scott ("Ye canna change the laws of physics!") rather than the pansy, goody two-shoes Geordi LeForge. (But at least we have Reading Rainbow.)  There are models and props that close-up you can tell are nothing but poorly painted pieces of wood and styrofoam, but at which you marvel nonetheless.  And all of this is going on while the theme songs from the five Trek series are being boomed into your head.  I'm in my element, and Mary is finally gone, replaced by the knowledge that it's been a long time getting from there to here.

For me, the piece de resistance of the entire exhibit was a recreation of the bridge of THE Enterprise.  (As Mr. Scott would say in a drunken TNG rant, "Show me the bridge of the Enterprise. NCC-1701.  No bloody A, B, C, or D.")  At heart I'm an Original Series guy, meaning that I believe that sometimes you can't talk it out and you just have to blast someone out of the sky.  So as I walked onto the bridge and stood by the rail, it like where I needed to be.  Sure, there was the Captain's chair, but it didn't feel comfortable.  You can't command while seated.  

There are some who believe that we all have past lives, and that if you look hard enough you can find out who you were from who you are.  Does it mean something that I've always read volumes about naval warfare and The Great Captains?  Does it mean anything that I'm a pretty good leader but a not-so-hot follower?  Could I be the last verse of the song "Highwayman?"  It's been a long road, indeed.

But wait, my reverie is interrupted; here's an exhibit staffer to take my picture.  And now someone else...some...well, tourist geek...wants to sit on the chair.  On MY bridge.  And as my reality comes crashing down, all I can do is take refuge in knowing that there's a candy store three flights down and to the right that makes caramel apples and an Orange Julius stand which
does, in fact ease the pain.

After the Mall we headed downtown to the film festival.  (The Teen, who is currently asleep as I write this pending his forty minute Voyage of Discovery each morning that we call Taking a Shower, has already posted his first movie review at thecriticalfrog.blogspot.com. Many more to come.)  Only been here overlooking the Mississippi for a few short hours but already like the place.  Woke up early and walked from the hotel, a brisk trot under gray skies to the one landmark I know of, which is the bronze statue of Mary Tyler Moore throwing her hat into the air at the corner of 7th street and Nicollet Mall. Took selfies.  Song is back.  She's gonna make it after all.  Me?  Somedays I'm not so sure, but I'll get a beret just in case. 

First glance means something to me, and I'm pretty sure I'm going to like Minnesota a lot. Incredibly nice people, the bird-like sing-song accent (don' 'cha know), delightfully unexpected multicultural diversity.  Even in politics, they either elect people who believe in doing genuine good and exhibiting common sense like Hubert Humphrey, Paul Wellstone, and Tim Pawlenty, and when they don't they at least recognize the process for what it is and elect buffoons (Jesse Ventura) or comedians (Al Franken).  There are moose, fish, Vikings, Timberwolves, Ole and Lena, and above all Goldy.  It strikes me as a place relatively free of pretense, where no matter how much money one has you still need to heat your garage and shovel your way out of the driveway in the dead of winter, and where politeness reigns because it takes up too much body heat to be angry.  

(Did I mention that as I sit at breakfast writing these notes at the Renaissance Hotel at the Depot in downtown Minneapolis, a place where the server remembers my choice of tea from the previous day and that knows how to DO BACON RIGHT, it's April and it's snowing?  When it's fifteen degrees higher and sunny even in my own stark Kansas?  Which probably answers the question about how this place became such a large metropolis.  You clearly have to huddle together for warmth. You get the sense that here global warming is not debated, but welcomed.)

I understand there's a lot more to explore in the Twin Cities, and I certainly intend to come back.  But not this time of year.  Perhaps the third week in July.  I understand that's when summer has been scheduled for 2016.

Family Affair

A brief note from The You Can't Make This Stuff Up Department:


In one room at the far end of the ER is a woman in her middle 30's complaining of abdominal pain.  At least that’s what she told the nurse, because her actual issue, once you get past the sunglasses with the four inch lenses that make her look like a Dollar Tree version of The Fly, is that she wants her IUD removed.  She needs it out today because her Legal Guardian, who has Power of Attorney for the patient because she is apparently "disabled" and getting Social Security, and who has (for the benefit of society as a whole) said the birth control device should most definitively stay in place, is out of town and this is the patient’s chance to "escape" and get it removed.  


With her is a considerably older man who looks "well-seasoned,” to put it politely, and who appears exceptionally eager have this offense against nature removed so he can promote his lineage within her longing womb.  The drive to spawn is overwhelming, like that of a doomed salmon fighting to get upstream, so of course an ambulance was required to get her to the ED in record time.  In Star Trek terms (and are there any other worthwhile terms?  I think not), it’s the Ponn Fa'ar.  It's Amok Time.  


When informed that I do not remove IUD’s as part of my practice, and even if I did I cannot remove her IUD against the wishes of her Legal Guardian, she says she is going to sue me, sue her Guardian, and head across the parking lot to our sister hospital in town (whose name she prefaces with a word that rhymes with “clucking”) where they will most assuredly do what she wants.  She also drives us into heartfelt introspection of our behaviors us by saying she will never come to our hospital again, in what may be thought of as a successful long-term resolution to our problem.  


Down the hall is another woman of similar age and weathering who is short of breath.  She started gasping for air as she was running down the street to the hospital to be with her sister, who has abdominal pain and came by ambulance.  She is accompanied by a teenage male who somehow is able to answer questions about her last menstrual period.  


As I’m chatting with her, the older man from the first room walks in.  My new patient identifies him as her father.  Seeing my face as I assemble the pieces in my head, she quickly backtracks to note they’re all just “really close friends."  


I’ll bet.  


Where’s the Jerry Springer Show referral line when you need it?  


(Afterthought:  This whole episode reminded me of something we need to add to our Electronic Order Entry System.  When you order an x-ray on a female patient of a certain age, you are always asked if the patient is pregnant or not.  Given our clientele, there really should be another option.  It would read something along the lines of, “Please, Lord, No!”)

Poisons and Productivity

The pharmacist in the ED sets a packet of paper in front of me, proclaiming with more than a hint of irony that this is from the Poison Control Center.  She says it like this because as far as he can tell, the Poison Control Center does very little besides telling people to go to the ER and sending faxes, and has nothing at all to do with the real work of patient care.  The Poison Control Center used to be a thing, though...tucked way deep in the bowels of most children's hospitals, they maintained a mythic quality as the repository of all toxic expertise which they would deign to share with the poor mortals when asked on bended knee.  However, as more ER residents rotated through these hospitals, we saw the Poison Control Center for what it was, a technician in a windowless basement room playing solitaire waiting for someone…anyone…to call so they could read to them off a microfiche (yep, I'm that old) whatever the latest case report was from the Lesser Mongolian Journal of Yak Toxicity.  Eventually, the docs figured that we can read a microfiche, too; and as time elapsed we could do one better and look up things on the internet.  Plus clinical overdose management has progressed remarkably, and in many ways has retreated from some of our more aggressive care of days gone by.  No more pumping stomachs, no more ipecac-barfing, no more drinking the charcoal and pooping out briquets.  (Pro tip:  They still need lighter fluid, but watch out for the pockets of methane. They explode.)  I actually miss those days; as a true believer in the occasional benefits of punitive therapy, I thought it sometimes did a word of good for those people who were using pretend overdoses to manipulate others to go through a little discomfort themselves, perhaps as a reminder that actions have consequences.

Aside from a few specific antidotes, overdose management is essentially protecting airways, stabilizing vital signs, and managing complications, exactly like it is in any other patient.  It's all pretty basic stuff.  So now all the Poison Control center has to do is tell people to go the ER and fax things telling us that Yak spit is highly toxic to...well, nobody, but that there was a case report of a Westerner who got bit by a Yak in 1974 and was so afflicted he abandoned his wife and family and lived in a yurt for three years before resuming his role as the second-best insurance agent in Chillicothe, Missouri.  So we should probably admit the patient for observation just in case this occurs.  

 

*************************

 

One of the trends in emergency medicine is to reimburse physicians based on RVU's.  An RVU is a relative value unit, and it was created to quantify the relative work load, experience, knowledge and time commitment related to a particular medical procedure or patient encounter. The idea is that the harder you work, the more patients you see and the more RVU's you generate.  It's a variation of fee for service that basically means you eat what you kill.  And it's a radical departure from traditional emergency medicine pay which is based on a hourly rate.  

While I understand the desire to drive productivity through incentivizing physicians, I'm not sure that the RVU system is right for emergency medicine.  The RVU system works best when a physician has control over his patient population and daily workload.  In that event, you can choose to work harder, faster, and drive up more RVU's. The ER doctor, however, cannot control his patient load.  People either show up at the door or they don't, and you can't control for the complexity of the patients.  There is every chance for a doctor gets penalized because it's a slow shift or because critical patients or social catastrophes (and there's a lot of those) decrease your overall productivity.  But I also think the RVU system can act as perverse incentive.  On one hand, it encourages slipshod medicine, as the goal is to generate more RVU's by running patients through the system as fast as you can. Things can get missed, patient education can be compromised, and patient satisfaction falls as they feel "rushed" through the system.  On the other, it drives up costs, as one of the ways to escalate the RVU's without taking more time with the patient is to order lots of x-rays, lab studies, and consultations, sometimes by protocol even before a provider actually sees the patient.  

Those proponents of the RVU system might point out that a strict hourly salary promotes lethargy.  Why should someone work hard, or harder, if they're getting paid the same amount no matter how much effort they expend?  The answer to that, I think, is something as simple as professional pride.  Nobody wants to be known as the slowest doc in the group, and even less as an outlier even if your pace is off.  It irritates your colleagues who, at the change of shift, walk into a full waiting room and an ER full of half-done checkouts even on good days.  And if the behavior persists, eventually the group finds its’ way without you.  

I should also confess that there is a "sore loser" component to my complaints.  Reimbursement rates for RVU's were determined the same way all reimbursement rates were calculated; through prolonged lobbying, begging, and cajoling.  When the system came out, the clear winners were the more procedure-based specialties.  Which is why, with the same four years of training, an eye doctor can charge a small fortune for spending twenty minutes removing a cataract, while I get a fraction of the dollars for spending an hour with a critical patient saving their brain, heart, lungs, and everything else that makes that eyeball possible.  Not that I dwell on it, at least not too much.  My comfort is that primary care specialists (family physicians, pediatricians) have it a lot worse.  

(This reminds me of an entire sequence of jokes about doctors and money, courtesy of Drs. Kevin Dishman and Frisco Morse:  

How do you hide a dollar from an internist?  

Hide it under a wound dressing.

How do you hide a dollar from a surgeon?  

Tape it to the EKG.

How do you hide a dollar from an orthopedic surgeon?  

Tape it to the chart.

How do you hide a hundred dollar bill from a pediatrician?

It doesn't matter.  They've never seen one.  

Okay.  maybe you had to be there.)

 

********************

 

I had just gotten back from a meeting talking about RVU's when the Poison Control paperwork landed on my desk.  The patient had ingested something called Krud Kleener, which turned out to be a weak alkali, kind of like bleach.  Nobody dies from bleach.  (I've heard rumors, though, that everyone who drinks bleach gets whiter and starts to channel Neil Diamond.  I am, I said, to that damn chair.)  

Now, if I had been an RVU guy, I would have gotten a bunch of labs.  I might have given a dose of charcoal as well.  Maybe the stuff could have eaten though the esophagus or stomach and caused a perforation. I can look for that with an x-ray, or maybe even a CT scan. I could toss an EKG into the mix as well.  The fact that none of this would have been supportable by the medical literature is besides the point. Given a small amount of medical knowledge and a smattering of latin terminology, the enterprising clinician can justify anything. 

But I don't do that.  I don't do it because of any particular drive towards cost-efficiency or the practice of evidence-based medicine. I don’t because I'm lazy, because I know that nothing I could do is going to make any clinical difference, so why bother.  I also don't do it because I know there's got to be a good story here, because the patient drank from a bottle (brought to the ER)  most clearly labeled KRUD KLEENER, and I'm the kind of guy who's willing to kill his productivity to hear the tale.  

It turns out that unbeknownst to me, locked inside my HVAC-sealed workplace cocoon, it had been a hot day outside in the real world.  The kind that makes people who are standing outside watching a yard crew cut weeds want to drink something.  Anything, in fact, that looks like water, even if it says Krud Kleener on the bottle set aside in the corner of the garden trailer, because she was pretty sure that the crew had put extra water in there because, as you know, it was a hot day.  

At this point, I've already lost some RVU's by taking the time to hear the story.  So why not go ahead and cut my productivity to the bone with a little non-reimbursable patient education?  A little Socratic method, please.  

"I think you'll be just fine.  But what have we learned?"

"Well, it's not really that guy's fault for me thinking it was water."  

A patient pedagogical moment. "No, let's try that again.  What have we learned?"  

"That I should have stopped after the first mouthful tasted bad?"  

"True, but what have we learned today that will keep us out of trouble tomorrow? What should we do if it says KRUD KLEENER on the label?" 

There's a look of puzzlement, and then enlightenment breaks out on her face like the sun after a summer afternoon storm.  

"I don't drink it!"  

Another successful patient encounter, another crisis averted.  But done way too cheaply. No RVU's for me.  Should have ordered a CT scan.