Choices

I don't know anyone in medicine who's particularly happy with their career choice. (Okay, maybe the locums neurosurgeon who gets paid five figures per day to sit in a call room and say things like, "Yeah, that's pretty complex, and since I'm not really familiar with the surgical team here you'll better send that along to a referral center." What a deal.) However, nobody will tell you this. It's true that we may have occasional flashes of genuine delight or emotional reward, but most of physicians just gut it out, showing up for work each day, wading through the teeming masses, deferring work as much as we can (translated as "Go to the ER") and wondering why we're not working at a tire store putting tires on cars, because no one is unhappy when they have new tires; or stacking bottles at Liquor Kingdom, because nobody's unhappy when they leave there, either.

It's sad we feel this way because the actual practice of medicine is the easy part. Especially within the vast breadth of issues that come before the ER, there are only so many ways to do things and only so many ways things can go. It's actually very black and white. You're sick or you're not. You're alive or you're dead. You can't be "kind of sick" or "sort of alive." (And you most certainly cannot have fibromyalgia, because it doesn't exist.). Age, race, culture, gender identity, and a host of other characteristics don't change that basic biological equation. There's really not a lot of "gray zone," although that admission puts any number of academics, me in a past life included, out of business.

The Internet is rife with stories about why physicians don't like their careers, and I could list the common themes as well as anyone; administrative hassles, government mandates, insurance nightmares, falling reimbursements, crushing student debt, long hours. (The one they won't list...because it goes against the social narrative that everything is someone else's fault...is that physicians and patients themselves are often part of the problem.). While some of the articles I see are understanding of the physician's plight, most are of the "arrogant doctor deserve everything they get, whiney bastards" ilk. So when people ask me about my enjoyment of medicine...or lack thereof...I struggle with the best way to explain it.

After years of trying to come up with a politically correct solution, I now think that perhaps I don't actually have to explain it. Maybe what I have to do is turn the question into a riddle and let people figure it out for themselves.

In Room 1 is an elderly man with chest pain. In Room 2 is a child with a snotty nose. Room 3 holds a young woman who took an ambulance ride to the ER for a toothache (yes, it happens, and it happens a lot). Who do you see first?

It's an obvious decision, right? The person with chest pain might be having a heart attack. The kid with the snotty nose is just that. So you go and see the chest pain patient, ask careful questions and perform a focused yet detailed exam, take a moment to form your differential diagnosis, place judicious orders into the computer based on your assessment, and document your thoughts into the electronic medical record while the encounter is fresh in your mind.

Meanwhile, the wait time for the kid goes up, and the parents (if there are two parents) become frustrated because they've taken time off work, or away from sleep, or had to pay a babysitter to bring the child to the ER, or brought the other three kids because they couldn't find a babysitter and are now crawling all over the exam rom. Before you even address the issue at hand you're apologizing for delays, and it takes you extra time to not only calm them down, but also to explain how you care for a kid with a snotty nose, because in medicine, as well as in society, we've indoctrinated new parents into learned helplessness. So what could be a ought to be a five minute encounter becomes twenty, which prolongs your patient throughput times. And if you've tried to provide care without a plethora of labs and x-rays, all of such would prolong patient care times, you've decreased your potential reimbursement.

Maybe you can juggle two things at once. Maybe you can have someone quickly show you the EKG from Room 1 to make sure it's not a flaming heart attack, ask one or two questions of the nurse to get the show rolling, and let them start doing things according to a preset protocol whether the protocol is relevant or not. Meanwhile, you duck into Room 2 and get through the kid as fast as you can. It;s an easy case, there's nothing to do for it, and so what if you've not really had a discussion wth the parents? The kid is fine, and time saved. Then you can backtrack to Room 1 and figure out what's really been going on all the time, rolling your eyes at all the lab and x-rays that have been ordered when it turns out the patient's chest pain only happens on Tuesdays. At some point you go back and document both cases in the EMR, noting once again, as you've done before, that it takes exactly the same amount of time to document the care of a kid with a snotty nose or an adult with potentially life-threatening chest pain.

Here's a choice: Maybe you go see the toothache first. It's the quickest to be seen, it'll involve a minimum of charting and paperwork, and since there's no dentist in the ER and you personally don't pull, drill, or fill, it's a matter of a couple of prescriptions and an admonition to go see the dentist. Your average patient throughput time will certainly go down. You might even get a good patient satisfaction score. But if you do that, don't you just reward behaviors that abuse the EMS system and the entire rationale for the Emergency Department? And surely someone will call you back to Room 1 if the chest pain patient turns sour.

Now take this scenario and recognize that in most busy ER's in this country, your average ER physician is responsible for up to twelve patients at a time. And that the toothache (and maybe even the snotty nose), being a non-emergent condition, has probably been seen by a Physician Assistant or Nurse Practitioner, to be replaced on the doctor's agenda by something like abdominal pain, vomiting, vaginal bleeding, migraine headache, fever, possible injuries from a motor while accident or a fall in a nursing home, overdose, psychiatric crisis, or chronic pain, all scenarios in which it's incumbent upon the physician to do something to make sure there's no actual emergency, but not do too much to take up too much time or generate an excessive bill. All the while navigating family dynamics, patient expectations, social needs, clinical disposition, and appropriate pain management with the inevitable negotiations that accompany them all.

(As an aside, our ER has started giving out cards that list the Patient Advocate's phone number as part of our discharge paperwork. Not a bad idea, I suppose; if people have questions about their care, or their bill, they ought to have someone to call. But when you read the card it says to contact the Patient Advocate if you have "concerns" about your care. Nothing there about compliments. Which lets you know exactly where the Patient Advocate, as well as Administration, stands in reference to doctors and nurses. Words matter.)

It's an extreme example, of course, but it serves to illustrate the point that emergency medical staff (and, to a lesser degree, all health care providers) are working under a set of inherently contradictory mandates that are plain to everyone involved in patient care but are absolutely invisible to those in the corporate suite: The belief that you can, with no changes in resources and increasing patient loads, have faster greeting times, faster turnaround times, higher billings, and higher patient satisfaction, all at the same time. (Quality of care is an afterthought, and if there's a problem it's time to come down on the physician, for the hospital is not in the practice of medicine and it's simply not right to recognize any pressures or mandates the hospital might put upon the physician as contributing to any errors that might be made.)

I've had good bosses and bad bosses, but just like you can pull some valuable lessons out of a bad relationship (which is why I like sushi and know what an eyelash curler is), my worst boss did teach me something that I still think holds true. (Personally, I think he was an idiot, so I assume he got it from somewhere else and was able to read it off an index card.) It's that in health care:

(Access) x (Quality ) = Cost

Working through this equation, recognizing that access is a "people" number, quality is whatever we happen to define it as at the moment, and that cost is not always counted in dollars but can be counter in time or lost opportunities, it's clear that the paradigm that all things are simultaneously possible is fatally flawed.

Let's say that the number of patient being seen ("access") is flat, and improved patient satisfaction is our measure of quality. We know that time spent with the patient is the prime determinant of patient satisfaction. Patients want to move through the system, but they don't want to feel part of an assembly line. So using the equation, increasing patient satisfaction necessarily increases throughput times. We also know that another determinant of patient satisfaction has to do with the amount of care provided in terms of testing and prescriptions. If that's our measure, then costs in dollars rise.

If we want to decrease costs, ether as dollars or time, something else has to go. Each provider needs to see less patients (decreasing the access number) or patient satisfaction must fall. This is true even if we use (heaven forbid) true quality of care as defined by clinical metrics as our outcome goal. It's health care stoichiometry. It needs to balance.

I don't know the right answer, other than I don't think there is one. I would say that good clinical care is the optimal outcome, but within policy and administrative circles that is clearly no longer the case and that horse has long ago left the barn. There can, in fact, be no right answer when your goals are at odds with one another. What I'm hoping is that someday someone far above my pay grade will actually admit, in a nod to Spandau Ballet, that they know this much is true. But I have no confidence that this will occur before even more physicians and nurses, exhausted and burned out, become mere wage earners trapped in their jobs rather than the caring and compassionate professionals most of us wanted to be.

No, there's no right answer, at least not one that I, as an individual physician doing patient care, will ever be privy to. The Administrator du Jour, or the Administration du Four-Year Term, will decide what the right answer is for now, and undoubtedly one component of the answer will be that the providers are just not doing things right. Policies will be written, institutions will undergo "culture change" and "rebranding," metrics will be compiled, and a couple of months later we'll be back where we've started, with administration spending great whopping gobs of cash and rewarding themselves for non-existent accomplishments and providers feeling once again disheartened and disillusioned. No matter how many times you rearrange the deck chairs on the Titanic, the ship still goes down. And while those on the top decks are offered first place in the lifeboats, those in steerage...your doctors and nurses...are locked behind iron grates below decks and left to drown.