Wednesday, November 11, 2015

"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

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 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

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...

Sunday, October 4, 2015

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.

Monday, June 1, 2015

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.