Agraphia Medical Tragicomedy


The Patient Satisfaction Dilemma

I saw an exceptionally malignant patient with back pain a few days ago.  Readers who work in an ER know exactly what I mean just from that statement; for my lay readers, let me try to paint a picture.  He was a 50-something, shabbily dressed guy in somewhat of a constant state of disrepair.  There was a musty odor of tobacco about him, and when the nurse entered the room he sneered "Oh, there you are.  So there IS someone actually attending patient needs today.  Get me a damn soda, I'm thirsty."  He had been triaged, registered, and taken to a room within 25 minutes of arrival.  His wife piped in, "Make it a Coke for him and a Mountain Dew for me.  We don't do Diet."

I walked in the room to a hostile environment.   His wife was tapping her foot on the floor impatiently, lips pursed, and apparently we were fresh out of Mountain Dew.  He had his arms crossed and began to lay into me before I could say a word.

"I want an MRI.  I hurt my back lifting something a couple hours ago, I've had a bulging disk before, and I've been waiting now for the better part of 30 minutes to see ANYBODY who is competent around here."

I took a mental breath, calmed the raging inner demons, and introduced myself.  I apologized for not seeing him earlier as I had been performing CPR in another room and broke away just as soon as I was free.

I'll cut the story short here and get to the chase.  He left the ER with a diagnosis of back sprain sans MRI, shouting at staff, extremely angry... but it was clear from our first interaction that this was inevitable.  Interestingly, he didn't come to the ER for pain control - he came because he wanted an MRI, and was livid that I wouldn't give him what he wanted.

This gets to the crux of the matter at hand.  There has been a rising emphasis on patient autonomy in medicine, a deliberate shift from the paternalistic attitudes of physicians of old.  It is one of the four central "pillars" of medical ethics; Autonomy, Beneficence, Non-Maleficence, and Justice.  Most of the time, it is a good thing.  I involve patients and family members on their medical decision making as often as possible.  If I'm waffling about admitting a patient to the hospital, I'll ask them, "do you feel comfortable going home tonight?  We can try home therapy first and you can always come back if you aren't doing well."  I am often surprised by how adept patients are about making these decisions for themselves.

There is, however, a group of patients we'll call Generation WebMD, who think that 5 minutes of Googling has given them a provisional electronic doctorate.  This guy got it into his head that he wanted - no, needed - an MRI to diagnose his back sprain and wouldn't take no for an answer.

A scenario like this plays out every minute of every day in every ER across the country.  I have had furious mothers physically escorted from the premises by security guards over whether or not their child should get antibiotics for a cold.  Drug seekers have thumbed their switchblades at me when I inform them I will not be providing them with their fix.  One of our regular COPD patients has a strict "only three breathing treatments per day" policy to prevent him from overstaying his welcome, happily puffing on albuterol while lighting cigarettes and tampering with the smoke detector.

It's a huge issue.  Physician reimbursement nowadays is often linked to patient satisfaction scores.  Physicians at a neighboring ER, for example, have 25% of their entire salary directly tied to phone surveys.  That's a huge incentive to make sure people are happy - and people are happy when they get what they want.  Unfortunately, what people want when they come into a medical setting is often not what they need.

Here's the thing.  If all you do is constantly acquiesce to patient demands to make them happy... well, you aren't really a doctor, are you?  You're just a puppet medical license with a DEA number for hire.

I got into a huge argument with a woman a few weeks ago about antibiotics for two days of sinus pain.  She started screaming so loudly at me that a police officer walking down the hall peeked his head in.  She finally asked me a simple question, "JESUS, doc, why are you being so damn obstructionist about this?  All I want is some fucking AMOXICILLIN for my sinusitis!  It has worked EVERY OTHER TIME. It's not like I'm asking for a prescription for medical marijuana!  WHAT IS THE HARM?"

I've thought a lot about her in the past few weeks.   Every single patient I have seen dying of multidrug resistant bacteria, every news article I see about superbug TB, every case of clostridia difficile colitis - I have mentally told her, "This.  This is the harm.  The harm comes in physicians prescribing things that aren't needed, doing tests that aren't indicated, giving therapy just to say we did.  One day we will look back from the brink and realize we should have been more careful."

I could go on, but I've made my point.  It is so easy to roll over and give people what they want.  I fight this temptation every single shift.  Mom wants amoxicillin for her kid's "ear infection".  Guy wants Vicodin for back pain.  Family wants me to "do everything" for the 95 year old demented nursing patient.

With a click of a button I can easily do all these things, even when I know I shouldn't.  And I'll get paid more.  And I'll avoid lawsuits.  And my patient interactions will be far more pleasant.  I suppose in the end, I try to do the right thing instead of the easy thing because I firmly believe that my duty is to take care of my patients.

And sometimes, despite violent opposition, that means simply saying no.


Burnout On Its Way Down

I had a moment today where I caught a piece of my own personal burnout on its way down.

The longer I do this job, the more I really appreciate the nice, normal person that comes to the ER for an honest complaint.  They are unfortunately, shockingly rare, but they command a premium of my attention because I believe that there is potentially real disease.

In this case it was a 22 year old, well dressed, well groomed female who came in with a chief complaint of "toothache."  Normally this is enough to make every ER doctor groan - all these patients want are pain medications because we can't pull the tooth for them.  It's miserable.  We get used for vicodin scripts and mysteriously the "dentist appointment" they have in "4 days" doesn't materialize.  They come back the next friday and repeat the cycle. I wish we were near my old Los Angeles dentist, this kind of stuff would never happen.

This patient, however, was one of the rare cases of someone who has never been seen in the ER before.  No drugs show up on her list.  Well dressed, in college, very polite during the exam.  She had a massive, new dental cavity that was just killing her.  The rest of her teeth were impeccably taken care of.   It was Saturday night, she had called her Kakar Dental Group dentist Friday afternoon, and had an appointment set for Monday.

This same story gets told verbatim thousands of times in ER's across the country; the weekend visit, the soon-but-not-soon-enough dentist, the tylenol-isn't-touching-the-pain... but the context sets the stage. Does the patient look jittery, like they're withdrawing from their habituated opiate dose?  Am I their last bastion for some Vicodins before they can get in touch with their drug dealer in the morning?  Is it a kindly grandmother with threadbare clothes and no physical signs of disease, looking to supplement her medicare by selling Percocets to her grandkids' friends?  All of these happen, more frequently than you want to believe.

In this situation, there is a degree of mistrust towards patients, because all of the above scenarios are not uncommon.  We physicians want to help people.  We start out in this field with trust and honor and caring, but then it takes one patient, with one believable story, one time, to sucker you in. In this case, my patient. My wholesome college toothache came back the next day as a mixed vicodin/xanax/cocaine/alcohol overdose and I realize I got played.  And not just that I got played, but that I gave her that last drug to her overdose cocktail because I was too trusting and its now my fault she is sick.  The worst part is, the nurses who were more jaded than me raised an eyebrow when I said I thought she was "legitimate."  I fought for her against the rest of the ER staff.  I convinced them she needed pain relief.

So I see something like this, and I resolve that the next time, I won't get played.  Even if they look honest, people with a toothache can grit it out until they see their dentist.   They may not have dental insurance, they may not have the money to scrape together for anything more than dinner at Jack 'n The Box, but until they pay the $500 to get their root canal, they can tough it out with Tylenol.

It's a catch-22, really.  In this field you have to learn to spot the liars, call them out, and then act on your intuition.  My hope is to avoid being jaded but to entertain a healthy skepticism.  On the liberal pain relief side you contribute to the opiate overdoses that are plaguing our nation.  On the other you miss actually caring for those that need it.  There is no good answer.

This is how you wear down a person who cares too much, one plausible story at a time.



It has been a slowly dawning realization for me - I don't love medicine.

It's not Emergency Medicine, either.  It's medicine as a whole.  I'll give you a few examples:

48 year old male, chronic back pain, wants narcotics.  Angry he's waited for 3 hours to be seen.  Even angrier that I'm not going to give him his fix.  Both of us walk away upset from our interaction.  I don't enjoy playing bad cop, but I do it about 10 times per day.

35 year old female, morbidly obese.  Smokes 2 packs a day, comes in because she "can't breathe right."  Lungs sound like ash.  I give her some breathing treatments and steroids, she gets a bit better.   Goes home to smoke more.

10 year old male, BMI of 40.8.  Mom is upset that his pediatrician wanted to start him on antihypertensives and comes to me - an emergency physician - for a second opinion.  I can't argue; his blood pressure is 160/95.  He's eating a cheeseburger.

85 year old female, completely demented at baseline, dropped off by nursing home completely unresponsive.  Third time this year.  Family nowhere to be found.  Despite my better judgement, I intubate her because I'm supposed to.  Feel guilty afterwards for not just letting her pass peacefully.

I know there are patients out there who really, truly need me.  They are few and far in between, however.  Modern medicine, for better or for worse, now treats first-world problems.   We "care" for nursing home patients because families can't be bothered.  We write prescriptions for vicodin because we can't bear to fight with 5 people in a row today about whether or not they need pain pills.  We prescribe antihypertensives and statins and diabetic medications for people who don't fill them and then go eat at McDonalds.

The truth of the matter is, I just don't feel like I make a difference any more.  My fellow emergency docs know how frustrating it is to go through a pelvic pain workup on an 18 year old girl, just to find out that she only came to get a pregnancy test.  The ER, you see, is cheaper than the dollar store.  Or the drunk who just needs a place to stay for the night and complains of chest pain to get a "free" bed.  Or the dialysis patient who smokes crack, forgets to dialyze for a week and comes in dying.

There has been a lot of discussion in our journals lately about physician burnout.  It's been labeled as an epidemic of sorts, one that is getting worse.  There are a lot of reasons why. Here are a few of mine.

1) There is constant pressure to never make a mistake.  Some of this is legal - screw up and you get sued.  I like to think most of it is humanitarian, though.  You don't want to miss something and have someone get sick and die.  It's very personal.  Your mistakes are your own.

2) Patients can be miserable.  Especially in my field.  For instance, I go through phases with drug seekers.  Sometimes I'm easily able to blow them off.  Other times it really bothers me. I never wanted to have to spend every minute of every day being suspicious about human motivation.  Now it's part of every workday for me.  For better or for worse I've developed an incredible sixth sense about when I'm being played.  It's not a skill I ever really wanted.

3) You can't help someone who won't help themselves.  I think this one is the worst.  The vast majority of what I take care of is the patient's own fault.  Smoke too much, get COPD - come to the ER when you can't breathe.  Eat too much, get diabetes - come to the ER when your sugars are too high.  Drink too much, get cirrhosis - come to the ER when you get a GI bleed.  And then get upset at me when the wait times are too long, or I can't get you back to normal.

In the end, the easiest insulation is to just care less.  That way you don't get burned when the oxygen-dependent COPD'er blows off his own face by smoking with oxygen tubing.  Or the full workup you just ordered on your chest pain patient ends up being a waste of thousands of dollars because he was just trying to scam you out of vicodin.  Or the family of the diabetic you're treating for high blood sugar brings her an Oreo Blizzard from DQ while she's hooked up to IV fluids.

I've spent the last 7 years really, really caring about what happens to my patients.  I still do, but it's wearing on me.  For every great save I make, there are eight more patients for whom I was a momentary speed bump in their fast lane to destruction.

It's tough trying to hold on to the good things I do.  A kid almost died after an inhalation injury a few days ago.  I intubated him and saved his life.  He's back at home now, normal, with his family.  At the beginning of residency, I would have been excited about that for weeks.  Truth of the matter is, I don't really get a rise out of it any more.  Just one more patient out of thousands.

And so, I'm looking for a reason to keep going.  One that spans beyond a need to pay off loans or make a paycheck or not to throw away 7 years of miserable training. I know things will get better.  For now, though, it feels like I'm a tiny brick in a massive dam that is trying to hold back the constant flood.  America is getting sicker.

I'm getting tired of fighting.


Trapped and Free

4:55 AM, and I was dragging. My 12th day straight in the hospital, leaving a string of three call nights behind me with one left to go. Twenty patients to see before grand rounds at 7AM.

My knee has been hurting. I suspect it's from the miles and miles I've been putting on my body 14 hours a day, 90 hours a week, running around the hospital. I've been taking the stairs everywhere in an attempt to remain in better shape, but this morning it was too much. No coffee yet and too little sleep. I gave in and took the elevator from the 3rd to the 11th floor.

I leaned back in exhaustion against the side of the elevator, eyes closed. It whirred into life, and I let the tug of gravity pull me to the ground. The elevator reached the top floor and *dinged* quietly. I stirred, mentally preparing to start rounds.

And then, the door made a few feeble attempts to open, and quit. Servos whined to a halt. I was stuck in the elevator.

Funny, how things can change. Any other time I would immediately panic. What if I have to go to the bathroom? What if the cable breaks? What if the call button doesn't work? What if I can never get out?

Instead, pure, unabashed relief washed over me. I couldn't work while trapped in the elevator.

Zac, why haven't you finished rounds yet? The situation played out in my mind, There's so much to do today! We have to get on it!

Sorry sir, I quietly replied, I'm physically trapped in the elevator on the 11th floor, there's really not much I can do from here.

Well, I suppose you've got an excuse then. Take the day off.

I sat there for a few minutes, relishing the solitude. I planned out my entire day of rest, mapping out every delicious hour I would spend in each corner. Perhaps I'd take a nap right in the middle of the floor. I smiled. It was going to be a good day.

Then the elevator *dinged* softly again, and my hopes sank as I traveled back down. The door opened on the third floor. A tech stared at me in surprise, papers stuffed in my pockets, hair askew, sitting on the floor of the elevator.

"You alright, man?" he asked.

"Not really", I responded. I stood up, knee hurting, as I limped off towards the stairs.