Bread and Circuses, Water and Sewage

Customer Disservice

There are days when I explain to the family of a 98-year-old customer, in terror of the the inevitable end, that today is not that day and while the odds of their mother living another month are close to zero, she’s alert, reasonably comfortable, and they have some time to say what they want to say and do what they want to do.  There are also days when I must gently insist to a family that despite what they have heard about the mighty apparatus of American Medicine, it will be as ineffectual as casual prayers and there is only time now to steel their hearts and accept the inevitable end.

And then there are days when a simple customer, sorted in triage as a minor complaint, slowly evolves into a horrifically complicated ICU admission whose fragile life depends on the skill and vigilance of the entire Emergency Department staff…and even then the odds are not good.  That one will keep me in the Department long after the end of my shift, the extra hours of which gain me nothing materially.

On every day we risk our health in this dangerous profession where we are exposed to the concentrated sickness of the entire city.  We risk our careers, too, and our economic viability making thousands of decisions about customers with more medical problems and more medications than I once believed could burden one human being while held to a standard of care that tolerates no mistakes; the slightest of which (something as simple as not giving an aspirin) not only has the potential for disaster but can start the long, expensive slog through the court system where every victory is Phyrric and defeat, the out-of-court settlement, is always the preferred outcome.

And then nobody really pays us for our work although the usual drunks and serial abusers of Emergency Services, customers all,  loudly proclaim at the slightest affront to their august dignity that they are “paying our fucking salary.”  There are co-pays for some and none for others and some boldly steal medical care, the thought of paying one thin dime for the services of at least the highly-trained nurse who they regard as their personal servant having never entered into their head; medical care being, after all, just another public utility like water and sewage and nobody pays for those things.

The bureaucrats at my hospital have just gone through their annual mission statement contortion and have, on schedule, given birth to the usual smarmy slogan which is going to change the direction of the hospital and solve every one of its problems by focusing on the customer…putting the customer first…taking the customer seriously…making the customer the center of our efforts…making customer service a priority…ostensibly to increase customer satisfaction but more realistically because it is cheaper than hiring nurses to take care of the customers we’ve already got.

But this isn’t Wal Mart and the patients are not customers. Pretending they are degrades the patients and dehumanizes the practice of medicine by substituting clinical judgment and perception with the polite fiction that we are engaged in nothing more than a business transaction, one in which the customer is always right and which is now to be ruled by Press Ganey and Mammon, the Two-Faced God-Incarnate of the bureaucrat.

Come On Now…

92-year-old patient.  Demented.  The usual medical problems teased out of the the nursing home medication list and the family who insisted he was healthy except for the pacemaker, the feeding tube in the belly, the coumadin for a “heart problem,” the three strokes, the diabetes, and the emphysema (but he’s 92 so he must be doing well).  History of benign polyps in his colon.  Presented for abdominal pain after a colonoscopy earlier that day.

Why does a 92-year-old man with less than a fifty-fifty chance of living another year get an expensive colonoscopy?  I mean, it had better be a good reason.  Rectal bleeding.  Something like that.

“It was a screening colonoscopy,” said the consultant, “We removed a polyp.”

You have got to be kidding.  Remind me never to send you another patient.  Would it have killed you to have politely deferred the colonoscopy for another year just to see how things would shake out?

Of course, I was no better because I ordered the deluxe work-up with all the usual laboratory tests and the premium CT scan although his abdomen was benign and he was too demented to really get a handle on his exact symptoms.  In my defense and contrary to popular belief, please note that I don’t get extra money for ordering a lot of tests.  But I still squandered your children’s money, money which really belongs to our Chinese and Arab creditors and future masters, at a blistering pace.

My job is mostly ridiculous, on some levels anyway.  At least we sent the gentleman home instead of admitting him like the family wanted, “just  to be safe.”

“Just to be safe.”

The four most expensive words in all of American Goat Rodeodery.

We Just Get Headaches

I had a pleasant conversation with a recent immigrant from Cuba whose wife came to the Emergency Department with a severe headache that she volunteered was the worst of her life and had started abruptly.  Naturally with this kind of history and some reasonably high blood pressure we brought the Great Ship of American Medicine about and raked her hull with a full broadside of medical ordinance.  We were looking for a ruptured cerebral aneurysm and it took a CT scan of the brain (negative), a lumbar puncture (a “spinal tap”) which was equivocal, and finally a Magnetic Resonance Angiogram (MRA) of her cerebral vasculature to definitively prove that there was nothing really serious going on and she just had a bad headache.

The cost (to your children) was immense and on the way out the husband, who was extremely gracious and not a little impressed at the our thoroughness, shook his head in amazement and said, “You know, in Cuba we just get headaches.”

“We used to just get them here too,” I replied.

Something About the Culture of Medical Training

One of our junior residents did a particularly fine job of intubating a patient who had, to put it mildly, an extremely difficult airway.  You know, 600 pounds, no neck, a beard, and instant hypoxia when laid flat.

“Nice job,” I said after we got everything secured and the the patient moving towards the ICU.

The nurses looked at me in horror.  “Good Lord,” they seemed to say with their eyes,  “Don’t praise the residents, they might get big-headed.  Don’t you know you’re supposed to beat them down at every opportunity?”

Just thought I’d share.

22 thoughts on “Bread and Circuses, Water and Sewage

  1. Panda, you probably made that resident’s day by saying that. Keep up the great work dude.

    Let me ask a small question. With the socialized medicine masses gaining momentum behind the mountains of Mordor (sorry couldn’t resist quoting you), what do you think the job prospects are for EM? Do you think EM salaries will drop drastically, or stay relatively the same? Thanks for all your advice and enjoy the summer man.

  2. Wow…given the concern for a subarachnoid hemorrhage, I can understand the head CT. But an LP and MRA? That seems like overkill (but what do I know, I’m still a med student)…

    (If the CT is negative, you can still have a sub-arachnoid hemorrhage. The CT is specific (it will show you if there is a lot of blood) but not very sensitive (a little blood might not show up early). Positive CT equals SAH, negative needs further work-up.

    The lumbar puncture was a “traumatic tap,” that is, there was blood in Tube 1, 6300 RBCs, decreasing to 550 in Tube 4 (we draw four tubes typically). There is no good literature to support a “cut-off” for a negative tap. You can have a traumatic tap and a SAH. Some neurosurgeons insist that less than 2000 RBCs isn’t significant but, like I said, there is no good evidence to support this and it’s not the neurosurgeons career on the line.

    So with an equivocal lumbar puncture which has a small chance of representing a small SAH, further testing is required especially in our zero defect world where a missed SAH can cost the hospital $30,000,000 in a lawsuit compared to $2000 for an MRA. For my part, I’d send a patient home who presented with a classical history for a SAH but who had a negative LP (0-10 RBCs) and I would probably start with the LP which is both specific and sensitive for SAH (as well as infectious causes of HA) except that in some cases you might want to get the CT first which is non-invasive and can show other causes of headaches (masses, big bleeds, obvious strokes). Although I’m not sure how good the evidence is for this, a small subset of patients who have masses could theoretically herniate their brain stem if you draw off CSF (although nobody I have talked to has ever heard of this happening).

    But you see my point. The couple of dozen cases of actual SAH I have had were all so clinically obvious with hypertension, nausea, thunderclap onset, and neurological findings that you almost didn’t need to order any tests before calling the neurosurgeon. Most, however, turn out to be nothing and I am so far 100 percent when it comes to ruling out SAH by clinical judgment. But I only have to be wrong once to negate any attempt I might decide to make to be a good steward of your Children and their Chinese and Arab master’s money.-PB).

  3. Man can’t say too much about your piece. Your thinking a little more elevated than my own. I’m kinda’ glad I don’t work in your field. I’m studying to be a clinician. That’s my major. I’ll be dealing with drug addicts and alcoholics. Why am I doing this? I just want to extend a hand where a hand was once extended to me. Working with people is supreme. not that we’re God but it gives us the chance to let God use our lives if He chooses.

    (Look, you can’t call your blog “Need4truth” and then disparage conservatives and anybody else who believes that printing money to pay for social welfare may not be a fantastic idea. Not to mention that disliking President Obama does not make one ignorant, uneducated, reactionary, or stupid. I am a conservative, extremely well-edumafuckingcated, well-read, an engineer, a physician, and something of a writer and I dislike the guy for many, many excellent reasons.

    I note with interest that the “Dissent is the Highest Form of Patriotism” bumper stickers have all but disappeared from the country.

    Also, getting your political, economic, and historical perspective from John Stewart does not exactly give you a lot of credibility. To think they once made fun of Ronald Reagan because he had been an actor. -PB)

  4. Strange request here but if you can fulfill it you would be my hero (pshaw, like you already aren’t)

    -I have read your entire blog and I think you have what it takes.
    Can you completely and definitively remove any and all desire I have of going into medicine. Horror stories, worst case scenarios, your own personal advice, etc. Disprove all my self righteous bullshit disguised as prestige and responsibility and making a difference.
    The reason I ask this of you is because all I want to do is go to dental school, enjoy my career/day to day work, and make bank not having to deal with all the extra layers of bullshit in medicine but I can’t shake this feeling that I am missing out on something and don’t want to look back in regret.

    (BTW I avoided the massacre once already as I pulled my med school interviews last year when I got cold feet, but I want to bury my med school applications for good)

    You can post either here or to my email, but I figure if you post it here it will be a warning to ward away future unsure pre-meds, like a big, stinking, rotting carcass of what once was a noble profession. (This isn’t directed toward physicians, just the circumstances and situations that they have to deal with now are depressing at best). A cornucopia of medicine’s awfulness, if you will.


  5. and if it helps the areas that I have interest in medicine so far are
    -path, optho (maybe)
    -doubt I am crazy enough for ortho

  6. matt,

    You write (in mostly complete sentence) that you read his entire blog and follow up by requesting stories and advice. Huh? Are you sure you read the same blog (which is full of stories and advice)? Now you request customized advice?

    My answer would be that you won’t be missing out and you won’t regret it. If you really mean that “all [you] want to do is go to dental school, enjoy [your] career/day to day work, and make bank not having to deal with all the extra layers of bullshit in medicine” then you’ll be just as happy or happier as a dentist. If you had to look back and ask “what if?” what do you think you’d be missing out on? Greater prestige? A bigger house? hotter wife?

  7. Watch out, Matt. Dentists are going to be the next to feel the pinch. No one is safe from government interference.

  8. sorry it was written kind of quickly. ya I agree that he has basically been saying this the whole time, it’s just a big decision for me. I mean, I can’t figure out to make for dinner, how am I supposed to make a decision of this magnitude. I had always figured I would be a physician from a young age (ya, I know, stupid) so I think its just hard to let go.

    Just ignore my post, my bad

  9. matt;

    Some advice from a dentist.

    Go work in a few dental offices as an intern or assistant for a few weeks. If, after doing so, you would still be happy to eat a mile of crap just to be a dentist, then more power to you. I recommend that you get the analogous experience in medicine. You may discover that you would not like either and save yourself a lot of grief. You also may discover the opposite and proceed with confidence.

  10. PB:

    How did it take me so long to find this blog? I used to frequent SDN simply for your posts–the pixelized diamonds of the cyber-rough–but there is a lot of rough, and my time is limited. Now I’ve found this mine of medical wisdom, and on the same day that I irrevocably quit my job flying jets in order to start medical school in the fall as a 30+ y/o.

    By the way, I once took my kid to the ER for a splinter.

  11. “And then nobody really pays us for our work although the usual drunks and serial abusers of Emergency Services..”

    A panda, How much is your starting salary 200K, 250K, or more, and of course the productivity bonuses. Nobody is saying your job is easy (I am also a doc) but to make it sound like you are a catholic priest with a poverty vow. Get a fucking clue.

    (While your knee was jerking you missed my point which is not that I am not paid but that people abuse Emergency Services because they don’t have to pay. See my point?

    But come to think of it, why should anybody be forced to give away their goods or services? Should the owner of a grocery store, if he makes more than $200K, be forced to give away goroceries or allow people to shoplift? -PB)

  12. Hey panda, you must be done with your residency or at worst a week away from finishing. I wanted to tell you congratulations dude. Enjoy the $ while your still can. After you give the wife and kids some much needed attention, I hope you do end up writing a book. Hell, just string together some of your blog entries and I’d pay 10 bucks for that. Enjoy yourself man.

  13. ” We risk our careers, too, and our economic viability making thousands of decisions about customers with more medical problems and more medications than I once believed could burden one human being while held to a standard of care that tolerates no mistakes;”

    If this were the standard of care, you’d have a point. As it is, you don’t. As for your economic viability, you have no idea what the risk to your economic viability is with any decision. I realize that taking everything to the extreme is your “style”, but you lose credibility at some point.

    “But come to think of it, why should anybody be forced to give away their goods or services? ”

    Did someone force you to sign a contract that compensates you in this manner?

  14. Reminds me of a news feature I saw where a female college student went to the ED with stomach pain and they did a CAT scan as a first line of investigation.

  15. DUDE! it’s June 30, and you must be done with residency. Congratulations! I can’t believe how long I’ve been reading your blog (the entire duration of your EM residency, and a good chunk of your first year at Its-Name-Shall-Not-Be-Spoken), and I can’t believe you’re done. You deserve it. Go buy your wife something nice.

  16. Dr. Panda. Accidentally came across your site. Love your blogs. I am a neuroradiologist and share your views on many aspects of medicine and politics. As for advice on medicine, once Obama and Pelosi get done, there will be absolutely NO financial incentive to spend years in study and thousands of dollars in debt. I do not perform a case without the thought of a law suite. Thanks for your thoughts. Keep it up.

  17. Panda,

    I’m 26, will be going to med school soon, and have worked in a mid sized suburban trauma center for 2 years now. Truly, you have an insight few have and fewer are willing to speak. I’ve been reading your blog for almost 2 years and this is my first time writing. I just wanted you to know how much my ER experience meshes with yours. I feel beat down on a regular basis, am appalled at how much money, time and resources are blatantly wasted because of how the system is set up, and regularly question my sanity for wanting an MD. I’ve cried at infants dying in my arms and shaken my head in disgust after I’ve broken the ribs giving during chest compressions on a 95 year old who hasn’t spoken or moved in a decade. But for me, every once ina while, I get a patient who looks into my eyes and sincerely thanks me for helping them. Making them feel safe, feel better, saving their life, their sons life, and that one moment makes it all worthwhile for me. Preach on, Brother Panda.

  18. Panda, it’s a great blog, and whether you’re doing it for catharsis or to share some common experiences with your fellow EM docs, you’re really doing a public service. People will inevitably find this–and you, and they will get an earful of a message they really need to hear. So please keep it going, even if and when you start making a much more comfortable living.
    Just to give a little glimpse of life on the other side of that pull-curtain, however:
    We just took our mom-in-law (62, youthful, no bad health habits) in for a “routine” hiatal hernia surgery a few months ago, and a silly chain of doctor and nurse mistakes–and the aftermath–have pretty much wrecked her life. The mistakes were all eminently avoidable, and they were much more serious than forgetting an aspirin. But that’s not the point I want to make. The point I want to make is that at every turn, we took great pains to be cordial and polite; to defer to the doctors’ and nurses’ wishes (I was brought up in the midwest; I believe in having good manners). It was NEVER a case where we felt we were the customer so we deserved this or that…
    However, our mom (and the rest of us, for that matter) were treated brusquely by almost everyone we encountered in the posh private hospital here in Atlanta whose name I’m sure you’d recognize. They failed to take our mom’s situation seriously, and now she finds herself unable to walk, climb stairs or drive–and she just lost her job (and will soon lose her all-important high-priced health insurance policy) as a result.
    Next stop for her: Medicaid.
    I couldn’t agree with you more about one thing in particular: the transaction between doctor and patient cannot and must not be seen as a business transaction first and foremost; and the silly emphasis on “customer service” is just so much fiddling while Rome is burning and our nation’s healthcare industry careens toward a future where it becomes so expensive that we allow the politicians to ruin it just because we’ve run out of time and options.

    But the reason hospital administrators repeatedly try this same tired old “customer service” path–aside from the fact that it doesn’t require any creativity or original thought–is that patients like our mom have been on their ASSES about the staff’s rudeness, the perfunctory 30-second conversations, etc.–the same things that led hospital staff to make a chain of mistakes that turned our mom into an invalid.

    For every uninsured moron who stands in your ER and demands gold-plated service, I would submit to you there is a patient like our mom, who has paid for her insurance; has not asked for any favors, and who nonetheless receives disastrously bad care AND has to put up with a lot of attitude on top of it. It’s just something to remember, I think, as you go about entering what should be an outstanding career.

    I know you are not sparing anybody in your commentary–fellow doctors included, and I applaud you for your intellectual honesty. Just remember that the same machinery whose gears crush doctors’ initiative also maims a good number of patients whose only mistake was believing there is such a thing as a “routine” hospital stay.

    Keep up the fantastic work!

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