Brighter Than You

They say the title does not make the man, and that’s also true in medicine. There are plenty of people out there who are book smart but lack common sense, and some of them carry the title of physician. It's like the old joke about what they call the guy who graduates last in his medical school class. The answer, of course, is “doctor.”

I have an ego as much as the next guy, and I like to think that I’m a reasonably bright citizen. But I also like to think I know my limitations. I know, for instance, that despite reading the CDC guidelines I will not survive the Zombie Apocylaspe, as I’m fairly certain the ability to sporadically blog and complete paperwork for maximum reimbursement pales compared to the ability to kill your own food and build your own fortress. (This is why my son already has reservations to live his post-Apocylatic days with my sister and brother -in-law, who have these qualities in spades.) I also know that I have trouble keeping my shoes tied, like to drive in the left-hand lane, think recording ATM withdrawls in the checkbook is only an option and not a requirement , and am a relatively poor parallel parker.

So I’m fully aware that there are folks in medicine who are a lot brighter than me. That opinion isn’t based on what you might think, like who’s a “specialist” and who’s not. The truth is you get be a “specialist” not because you’re the best at what you do, but because you’re willing to slog away, overworked and underpaid, for umpteen extra years for others who, by dint of seniority and not by quality, have you to do their work for them. And it’s not that hard to become a specialist. If you’re willing to go anywhere, there’s always a training spot somewhere. (A significant reason that I’m an ER doc and not a plastic surgeon is simply that I didn’t want to get beat up for five years of general surgery and two or three more of plastics when I could sail through relatively unabused in three years of ER. A powerful work ethic has never been one of my strong suits.)

My personal view…and one, I suspect, shared by many ER docs…is that most specialists can’t work their way out of a paper bag. They are very, very good at dealing with the handful of things they do routinely (and at high cost). But you’d be stunned at the number of “collegial” phone calls I get from doctors wanting to know what to give their kids for a cold (“Tylenol” is always a good start) or what’s the best thing to do for a sprained ankle. In fact, that was one of the things that first attracted me to Emergency Medicine, as it seemed that ER docs were the only people left who actually knew how to do all those basic things you always thought a doctor…well, at least a doctor on TV…should do. Twenty-five years in, I recognize that was poor basis for a lifelong career choice, and I recognize that the inability of other physicians to take care of the simple things means there are an infinite number of reasons for “real doctors” in their offices with normal hours, the ability to control their workload, and the benefit of actually being reimbursed for the patients you see to use the ER as a convienent whipping boy. But the optimism of youth won out, and now I’m too old with too many mortgages to do something else.

One of the more pleasant discoveries of working ER in a more rural setting is that, in fact, there was a reason you were in the top half of your medical school class. Out here I’ve seen both the best and worst of medicine. There’s the best, because I truly believe that the single most difficult thing to do in medicine is to be a good family physician in a rural area. You’ve got to be able to manage the greatest spectrum of care with the least support, and do it to the same standard as the guy at a teaching hospital with specialty backup for each gonad. There are a lot of these unsung heroes out there, doing the right thing every day in a manner I can’t even approach. But there’s also the worst, as rural communities starving for medical care take whatever they can get, and sometimes it’s that guy at the bottom of his class who’s still called “doctor.”

The problem is trying to figure out how I should respond to the baboon (and, as Groucho Marx notes in “Duck Soup,” that’s an insult to the rest of the baboons) who calls in the middle of the night to transfer you a patient that either don’t want to deal with or they’ve clearly mucked up. Most of the time you grab the phone with righteous indignation, determined to spit out in no uncertain terms exactly what you think of their clinical skills and to suggest that they get a new job selling door-to-door ham, where at least the product is already beyond help. However, after a few seconds reality sets in, and you figure that at least the patient is better off at a hospital that knows what they’re doing (that’s a polite turn of phrase for “get them out of there before someone kills them.”)

Purists…basically those academics, policymakers, and ethicists who exist in a sheltered world…might say that when we come across these scenarios, it’s our duty as physicians to turn in our less capable colleagues to the State Medical Boards. But doing so doesn’t help hospital volumes, and less patients mean less revenues. Making your concerns known in the public record so that the other doctor’s referrals go elsewhere does nothing but get you relieved from your job. Sorry, but that’s the real world. No matter how justified or correct they might be, squeaky wheels in the employ of another get no grease. They get fired.

(Interestingly, while there are always better and worse physicians in a community, I don’t see the same breadth of quality of care in more urban areas. I’m not quite sure why that is. Perhaps it’s because physician practice groups are larger and there are more doctors to “ride herd” on one another, and because hospitals have medical staff and administrative structures to ensure the quality of care. When you’re the only game in town, quality…or lack thereof…is what you say it is, and there’s no one to argue otherwise.)

Needless to say, I’m not about to tell you which physicians I’m thinking of as I write this or what exactly they’ve done. I’m fortunate that at the facility where I work, we have a pretty good record of getting patients out of the hole dug for them by their own doctors. But I can tell you one story that just gives you a sense of some of our referrals.

A middle-aged male was sent to us for evaluation after an intentional overdose of Phenobarbital. Phenobarbital is used mostly as a medicine for seizures, and in large doses it can cause sedation. Management of these overdoes is actually pretty easy. Make sure the patient’s breathing okay, and let them sleep it off. This patient, however, became angry when aroused and started to swing at folks. So rather than simply letting him sleep, the doctor at the other facility decided he needed to be transferred to us. He was apparently loaded into an ambulance with difficulty. He was unloaded with no difficulty at all, because there’s nothing like the steady drone of tires on interstate plus a heapin’ helpin’ or barbiturates to induce a nap.

I checked him out, fully expecting to see what had been advertised…a guy who needed to sleep. What nobody had mentioned…and I’m giving the other doctor of the benefit of the doubt by saying they didn’t know enough to look, because to take the other tack is to call them a liar…is that he also had the snot beat out of him, with multiple abrasions and bruises all over his head and face. That’s a pretty good reason to be agitated, don’t you think?

A few x-rays later (the same x-rays I know they have at the other hospital), we were back to Plan A, and he was admitted to sleep off his mischief. Maybe the other doctor just knew our beds were better for therapeutic non-intervention. But I can’t fault the other doctor entirely for knowing the patient had a better opportunity for competent care at our place. This was proved later that night when he got mad about not being in his hometown ER anymore, and decided to roam about the room flinging chairs and pulling towel dispensers off the wall. The hospitalist on the case decided that the best course of action was to bandage his cracked and blistered feet.

You’re probably asking, as did I, why that was the preferred method of care. Was it out of compassion and understanding, a desire to build trust within the physician-patient relationship? Perhaps it was a show of humility by the physician, a bold statement of service with a Christian precedent?

Turns out she did it because it was smart medical care. With his feet wrapped in gauze, he couldn’t get any traction on the slick, freshly waxed hospital floors. So when he tried to get up, he’d slip back onto the bed. Sure, he could still yell, but hospital property was no longer in the air. It was a flippin’ brilliant move.

See, there’s another doc who’s brighter than me.