Agraphia Medical Tragicomedy


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.


A Tax For Cigarettes

I saw a cardiac patient today; 3 stents, COPD, peripheral vascular disease... the whole 9 yards. While asking him my standard social history questions (smoke, drink, do any street drugs?) he hung his head low.

"Yeah, my doc tells me I gotta quit, but I can't get down to less than a pack a day."

It's something I hear all the time. I've talked to smokers who are crack and heroin addicts - they say that the nicotine urge is worse than any other addiction they've fought.

For better or for worse, patients seem to focus on the lung cancer aspect of smoking. I suspect it's due to a particularly effective ad campaign in the past few decades, but the truth is, smoking is far worse with regards to other diseases. Tobacco, whether chewed, smoked, or snu'ed causes a huge variety of vascular diseases.

I figure it should be easy enough to calculate the cost of a pack of cigarettes. Ask a random sampling of ER patients how much they smoke per day (we measure tobacco use in pack-years, i.e. the number of packs per day they've smoked times the number of years). Get permission to access their healthcare records, and calculate the differential in healthcare costs between smokers and non-smokers.

Take that differential, divide it by pack, and add it as a healthcare tax.  I support people's right to make bad choices; I also support their right to pay for those choices.

Your thoughts?