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.