Another Voice from the ER

(Steve Bohannon, a friend and fellow ED doc, sent me this piece the other day. It's a Letter to the Editor from another emergency physician colleague in the Northeast, with his take on emergency care. I really enjoyed it and think he's right on the money...hope you do too. Thanks, Steve!)

Sunday, October 11, 2009

Pittsburgh Post-Gazette

Emergency departments are distilleries that boil complex blends of trauma, stress and emotion down to the essence of immediacy: What needs to be done, right now, to fix the problem. Working the past 20 years in such environments has shown me with great clarity what is wrong (and right) with our nation's medical system.

It's obvious to me that despite all the furor and rancor, what is being debated in Washington currently is not health-care reform. It's only health-care insurance reform. It addresses the undeniably important issues of who is going to pay and how, but completely misses the point of why.

Health care costs too much in our country because we deliver too much health care. We deliver too much because we demand too much. And we demand it for all the wrong reasons. We're turning into a nation of anxious wimps.

I still love my job; very few things are as emotionally rewarding as relieving true pain and suffering, sharing compassionate care and actually saving lives. Illness and injury will always require the best efforts our medical system can provide. But emergency departments nationwide are being overwhelmed by the non-emergent, and doctors in general are asked to treat what doesn't need treatment.

In a single night I had patients come in to our emergency department, most brought by ambulance, for the following complaints: I smoked marijuana and got dizzy; I got stung by a bee and it hurts; I got drunk and have a hangover; I sat out in the sun and got sunburn; I ate Mexican food and threw up; I picked my nose and it bled, but now it stopped; I just had sex and want to know if I'm pregnant.

Since all my colleagues and I have worked our shifts while suffering from worse symptoms than these (well, not the marijuana, I hope), we have understandably lost some of our natural empathy for such patients. When working with a cold, flu or headache, I often feel I am like one of those cute little animal signs in amusement parks that say "you must be taller than me to ride this ride" only mine should read "you must be sicker than me to come to our emergency department." You'd be surprised how many patients wouldn't qualify.

At a time when we have an unprecedented obsession with health (Dr. Oz, "The Doctors," Oprah and a host of daytime talk shows make the smallest issues seem like apocalyptic pandemics) we have substandard national wellness. This is largely because the media focuses on the exotic and the sensational and ignores the mundane.

Our society has warped our perception of true risk. We are taught to fear vaccinations, mold, shark attacks, airplanes and breast implants when we really should worry about smoking, drug abuse, obesity, cars and basic hygiene. If you go by pharmaceutical advertisement budgets, our most critical health needs are to have sex and fall asleep.

Somehow we have developed an expectation that our health should always be perfect, and if it isn't, there should be a pill to fix it. With every ache and sniffle we run to the doctor or purchase useless quackery such as the dietary supplement Airborne or homeopathic cures (to the tune of tens of billions of dollars a year). We demand unnecessary diagnostic testing, narcotics for bruises and sprains, antibiotics for our viruses (which do absolutely no good). And due to time constraints on physicians, fear of lawsuits and the pressure to keep patients satisfied, we usually get them.

Yet the great secret of medicine is that almost everything we see will get better (or worse) no matter how we treat it. Usually better.

The human body is exquisitely talented at healing. If bodies didn't heal by themselves, we'd be up the creek. Even in an intensive care unit, with our most advanced techniques applied, all we're really doing is optimizing the conditions under which natural healing can occur. We give oxygen and fluids in the right proportions, raise or lower the blood pressure as needed and allow the natural healing mechanisms time to do their work. It's as if you could put your car in the service garage, make sure you give it plenty of gas, oil and brake fluid and that transmission should fix itself in no time.

The bottom line is that most conditions are self-limited. This doesn't mesh well with our immediate-gratification, instant-action society. But usually that bronchitis or back ache or poison ivy or stomach flu just needs time to get better. Take two aspirin and call me in the morning wasn't your doctor being lazy in the middle of the night; it was sound medical practice. As a wise pediatrician colleague of mine once told me, "Our best medicines are Tincture of Time and Elixir of Neglect." Taking drugs for things that go away on their own is rarely helpful and often harmful.

We've become a nation of hypochondriacs. Every sneeze is swine flu, every headache a tumor. And at great expense, we deliver fantastically prompt, thorough and largely unnecessary care.

There is tremendous financial pressure on physicians to keep patients happy. But unlike business, in medicine the customer isn't always right. Sometimes a doctor needs to show tough love and deny patients the quick fix.

A good physician needs to have the guts to stand up to people and tell them that their baby gets ear infections because they smoke cigarettes. That it's time to admit they are alcoholics. That they need to suck it up and deal with discomfort because narcotics will just make everything worse. That what's really wrong with them is that they are just too damned fat. Unfortunately, this type of advice rarely leads to high patient satisfaction scores.

Modern medicine is a blessing which improves all our lives. But until we start educating the general populace about what really affects health and what a doctor is capable (and more importantly, incapable) of fixing, we will continue to waste a large portion of our health-care dollar on treatments which just don't make any difference.

Michael Werdmann, MD
Chair, Dept. of Emergency Medicine
Bridgeport Hospital
Bridgeport, CT 06610