Monday, February 28, 2011


The best care in the ED is often tough love. Tough, as in severe and confrontational, with no chance of marshmallows by firelight and the sonorous hum of kum-by-ya. This knowledge no doubt will cause grave issues for medical sociologists. Medical sociologists are those people who tell us how, in the ideal world, physicians should provide clinical care. And a minority of them are genuinely helpful, like when they give us insights like always sit down when providing care. (It puts the patient at ease, allows you to communicate with them at eye level, and they perceive that you’re spending a lot more time with them then you are. It’s also fun to wheel around the room on a roller stool, and if you have enough roller stools you can play a mean game of floor hockey in the wee hours of the night just after housekeeping has waxed the floors.)

The rest of the medical sociologists are totally useless. They remind us to ask open-ended questions and to give the patient plenty of time to express their hopes and concerns. This, if course, is the absolute antithesis of the ED focus on determining if there is an actual emergency or not within a minimal amount of time. They also note that we should think of patients as individuals with life stories and cultural variances, and not as “The Chest Pain in Room 5.” This is probably the right thing to do, but given that I can get hit with up to 40 people I’ve never seen before in a single day (and if it’s someone I know, it’s usually a repeat customer for all the wrong reasons), my choice is to either get to know them or individuals or do what I’m paid to do, which is to get them through the system in the safest and most efficient way I can. It’s a lot easier to do that if I can categorize them by illness or injury and implement a standard protocol for care; and all the patient goodwill in the world can’t excuse excessive throughput times.

But their lack of relevance is most pronounced when they talk about healthy behaviors and “theories of change.” Let’s say that Bob the Hittite (because there are no more Hittites, I run no risk of offending anyone) decides he wants to quit smoking gazelle. Most of us would think that, having come to this conclusion, Bob would flick the ashes from his last antelope limb and, with a heavy sigh and one last long inhale, set aside his vice for good. It would be a rough few weeks and he might gain a few pounds, and need to chew a few crocodile sinews in the process, but eventually he would feel better and learn to substitute a more healthy habit like idol worship.

A medical sociologist, however, would tell you that this isn’t what happens. According to Prochaska’s Transtheoretical Model of Behavior Change, here’s what really went on:

Stage 1: Precontemplation – “not intending to take action in the foreseeable future.”

This stage represents those happy years Bob smoked those gazelles before he coughed up a hoof and thought there might be a better way to enjoy his leisure time between hunting and gathering.

Stage 2: Contemplation – “intending to change with the next 6 months.”

Bob plans this out carefully, making sure that he quits when gazelle is out of season. Besides, dried gazelle is nowhere near as tasty as fresh.

Stage 3: Preparation – “intending to take action in the immediate future.”

Time to smoke up that stash of illegal Cuban antelope you’ve hidden under the rock out back…assuming the jackals haven’t gotten to them first.

Stage 4: Action – “making specific overt modifications in lifestyle.”

The gazelle is gone. It’s a tough day in the cave.

Stage 5: Maintenance – “working to prevent relapse.”

Because chewing on hamster just doesn’t do the trick.

Another particularly useless contribution of medical sociology in the ED includes the belief that all medical problems (and for the true believer, it really means ALL) are really a reflection of social ills. The latter principle led to one of my favorite memories from my Master of Public Health course. I will be first to admit that for one with free-thinking tendencies such as myself (I’m much better now), an MPH course is as close as you can get to living in a house inhabited by members of the Students for a Democratic Society. Everyone is very strident, and it’s made clear that non-believers are verboten.

We were doing a group project where we had to identify the social factors that led to eye disease in patients with diabetes. The usual candidates were trotted out…access to care chief among them…and then the breakdown of contributing factors kept moving along. Maybe access to care was a function of lack of transportation to offices and clinics. It could be the maldistribution of eye physicians in poor inner city and rural areas. Perhaps it was the lack of money to purchase private insurance in a world where physicians are reluctant to see patients on Medicaid. It could be a lack of health literacy, the inability of patients to understand how to properly use their medications. All of which are absolutely valid, but not entirely reflective of the ED world in which I live.

So I asked, “How about if the patient doesn’t want to take their medicine, or chooses to spend their money on something else?”

“You mean they have to spend their money on things like food and housing because they’re disadvantaged?” came to predictable reply.

“I was thinking more like beer and cigarettes.”

“They only do that because they haven’t been appropriately educated about the risks of alcohol and nicotine, and they lack the resources to find more healthy substitutes.”

I like to think I’m an educated guy, and the powers that be have given me enough initials after my name to prove it. But even I know that while I’m supposed to take antibiotics for a full ten days, I stop them after Day Five when I’m feeling back to normal. And I haven’t yet met a smoker who contends that cigarette use leads to better health. People know stuff, but choose not to act upon it. If I had been clever, I might have even said these individuals are permanently stuck in Pre-Contemplation.

Unfortunately, I am not that clever, and my internal filter fails me on more occasions than I care to admit. So as memory serves, my response came out as:

“So you’re telling me that those guys who drop into my ED every week, whose usual weekend routine is to go out, get drunk, and get their face bashed in with a pool cue, do so because society gives them no other choice? That it’s a lack of education that makes them decide that staying home and watching reruns of The Golden Girls is not a better, and less painful, option?”

(Yes, I really did use The Golden Girls as an analogy for alternative behaviors. I’ve been meaning to apologize to Betty White for years.)

What I learned from this experience is that medical sociology is done only in controlled settings, because real life might upset their expectations. This is why the only people who ever really listen to medical sociologists are other medical sociologists; advocates who can find unlimited support for their views that the problem d’jour is a function of the medical profession, the health care system, society as a whole, or anything except personal responsibility; and certain nurse practitioners whose academic training is focused on holistic care to the exclusion of actually getting anything done. (This is not to say that nurse practitioners cannot be a valuable adjust in the ED. It is to say, however, that it takes about three years for them to unlearn how to be a nurse and figure out how to be a practitioner.)

So the medical sociologist would be opposed to the “tough love” approach in the ED, because it does not value the patient as a unique individual with autonomy, who needs to both accept the physician’s advice while rejecting his or her paternalism, and who must be given time to go through the process of change. Tough love places blame solely on the individual and not on society, and the individual is the one who pays the price for their behaviors. And medical sociologists would vehemently disagree with the concept of “punitive therapy.” Punitive therapy is that medical care, while clearly directed towards helping the patient, is also designed to teach a lesson and inform future behaviors. For example, if you come to the ER with certain kinds of sexually transmitted disease, I can either give you oral medications or an injection. If you were the passive recipient of an STD or you seem genuinely repentant for your role in transmission, you’ll get the pills. If you are a repeat offender or appear to be without remorse, it’s the shot for you. Both clinically valid methods of treatment, and you can even make the case that with the shot, you insure patient compliance with care in someone who might not be motivated to complete their antibiotic course. But it’s also quite clear which approach carries a message.

The interesting part about punitive therapy is that most of the time, the patients leave you no choice. If you arrive with an overdose, you will need a dose of liquid charcoal (it is what it sounds like) to get whatever you’ve taken out of your system. I will ask you to drink it form a cup with a straw. If you refuse, I will have to ask a nurse to put a tube down your nose into your stomach to get the medicine into your gut. I will also need to get a urine sample to get a better idea of what’s in your system. (While I trust you, faithful reader, sometimes patients lie about what they’ve taken. Go figure.) You can pee in a cup, or I can have a nurse put a rubber tube up into your bladder, restraining you if needed in order to accomplish the task. And if you are drunk or otherwise unable to control your agitation without a valid medical reason to be so, and you take a swing or spit at any member of our ED family, I will have you restrained until you have either sobered up and have to face your family who has come to pick you up, or until law enforcement takes you away. And in all these circumstances you’ve done it to yourself, probably with a minimum of Contemplation.

Punitive therapy is not always physical. Sometimes it’s informational, as when you remind the intoxicated college student of the legal drinking age; or when you tell the alcoholic, on his fifth ED visit in two weeks and in early liver failure that there’s nothing you can do for him unless he’s willing to go to rehab. (His response to this information was to look at me and use a phrase similar to “Duck Foo,” indicating that he was still in Pre-Contemplation.)

And sometimes it’s therapy by omission. If use the ED for the purpose of acquiring narcotics, I am under no clinical obligation to accede to your wishes. I am under a legal duty to assess you for an emergency medical condition, and to treat you in an appropriate fashion. This treatment may include an explanation of my concerns about your use of pain medications and suggestions for follow-up with your own physician; I may offer you a non-narcotic medication to help you until you can follow-up or even a referral to a detox facility or short-term medication to ease your withdrawal. (You’d be surprised how many patients ask for ”just a few days” of pain medication to manage their withdrawal until they can get to detox….and the appointment is always the following week.) Your “punishment,” if you will, is that you don’t get what you want.

(This scenario illustrates that good medical care does not necessarily equal customer satisfaction, and the customer is not always right. It’s also why health care, when provided by independently licensed professionals at high risk of liability, cannot work in a pure customer-driven, free-market model. My job is not to meet the expectations of the customer. My job is to render high-quality, clinically appropriate medical care. While the vast majority of the time doing so means customer satisfaction, no matter what you do there will be a small percentage of times that what is medically appropriate is not what the patient wants. This fact is lost on the majority of high-level health care pundits, who assume that all patients are reasonable persons with reasonable thoughts, and that health care providers are simple line workers at a task. Come spend a Friday night with me.)

No physician I know wants to harm a patient, and most of us strive for complete patient satisfaction if we possibly can. And while the medical sociologists would disagree about the “paternalistic” attitude I’ve exhibited in making decisions for patients, and deride me for not achieving a “partnership” with the patient to achieve “mutually beneficial goals,” sometimes the role of the doctor is to act like Mom and Dad and insure that actions induce consequences.

Clearly, I’ve been Contemplating this for a while.

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