Author: medicallyfutile

Resist

“Thank you all for joining us today. We appreciate your time. We know you all are very busy and we hope not to take up too much of your time. Now, as you know, there are some changes we are instituting throughout the health care system and we wanted to take some time to review these with you. As you know, we have seen a slight drop off in our patient satisfaction scores and have been thinking of ways to bring those sevens and eights up to nines and tens. After much deliberation, we believe that one way in which to fix these issues is to have physicians perform twice daily bedside rounds. We believe that increased face time with patients and their families can help lead to more satisfied patients and hopefully higher satisfaction scores.”

“So, does that mean the number of patients we are expected to see will go down?”

“Huh? What? Well, no. That actually leads me to my next point. It appears the overall hospital census has begun to drop off slightly. Now, we know that it is the summer time, but we believe that we will need to scale back on physician numbers at least until the census picks back up in order to control costs. Starting in two weeks, we plan to decrease the physicians on per day to accommodate for this census change which will lead to an overall increased daily census load for each remaining physician.”

“We are already seeing close to twenty patients a day and now you want to increase those numbers further?”

“We know it may be an adjustment, but due to need for cost control we cannot justify having as many physicians on at a time as we currently do.”

“And you want us to not only see more patients but to see them twice a day?”

“Yes, we believe that this will improve patient satisfaction.”

“…. So, do you plan on providing us with note scribes in order for us to have more free time to see all these patients twice a day?”

“Well, no. That would cost money that we simply don’t have at this time. But now that you mention it, we did want to discuss issues regarding charting. We have noticed that not all the boxes regarding medication and history review are being promptly checked. Furthermore, we have heard from our documentation specialist that their queries are not being responded to in a timely manner and there is concern regarding diagnosis specifics in each note. It is imperative that each note is reviewed closely for diagnostic accuracy and that there is at least a twenty percent change each day for each note in order to ensure that each note is not simply being copied and pasted.”

“So, you want us to see a higher number of patients twice a day and spend more time on charting?”

“We want to ensure we are providing the highest level of care to our patients while maintaining the most accurate documentation.”

“What patients do you take care of?”

“What?”

“You called them ‘our’ patients. But you are not a physician. You cannot practice medicine. You cannot prescribe medications. What you meant to say was ‘your’ patients unless you also plan to go through medical school and residency. Do you plan to pursue the practice of medicine as a career?”

“No, of course not! What I am saying is that we are all in this together as a team. We are all in this to provide exceptional care to each and every patient!”

“Really? We are a team? Tell me, what changes are you having to make to improve patient satisfaction and decrease operating costs?”

“I don’t understand. What do you mean?”

“Well, you just informed us that WE are going to be seeing more patients, that WE are going to be seeing patients more frequently during the day, and that WE will be needing to spend more time combing through our notes to satisfy a ‘documentation specialist’. And seeing that none of those things apply to you, what changes are YOU making? What is your contribution to the ‘team’?”

“Well, as you know, myself and others in the administrative offices will be keeping a close eye on the daily operations in order to identify areas of improvement. Although we may not provide direct patient care, we do serve a vital role in maintaining sustainability.”

“That wasn’t an answer. You may play a role but it’s not a vital one. You spend eight hours a day performing about three hours worth of work fives days a week without ever having to work holidays. You spend your time in meetings which result only in more meetings in order to discuss which subcommittee to form to address whatever problem was originally brought up in the first meeting. You then proceed to find different ways in which to enforce arbitrary metrics and goals presumably as a means of maintaining control over those with actual power. Your contribution is to serve as an overpaid whip.”

“You seem rather hostile. Where is all this coming from? This seems rather unprofessional!”

“This is coming from the fact that medicine is no longer about treating patients as much as it is about satisfying these arbitrary metrics generated by people that don’t actually matter! This is coming from the fact that your recommendations towards change has everything to do about loading us with more work without any input from us. If it seems like I am hostile, it is because I am! But my hostility is not unprovoked. You launched the first salvo when you asked more from us with nothing in return.”

“I think –”

“What if we said ‘No’?”

“Excuse me?”

“What if we said we were not going to see more patients, that we were not going to needlessly round twice in a day, and that we were going to write our notes only in a way which benefits us? What then?”

“Well… Then… You would face disciplinary action!”

“Like what?”

“Like… umm… you may face a review board. You may even be fired!”

“All of us?”

“What?”

“Do you plan to fire all of us? Do you plan to fire and replace all of us overnight when we refuse?”

“Well… No. That couldn’t happen. How would the hospital run?”

“Exactly. How could the hospital run without us? We are the ones managing the care of patients and we are the ones that have the knowledge to do so. But do you think the hospital could run without you?”

“Well… There would definitely be issues.”

“Sure. But would the hospital shut down?”

“Well….”

“The answer is No.”

“What are you trying to get at?”

“I will be blunt. You have no control. You never did. Your power comes from our inability to say ‘No’. We are in control. We have the power. The hospital exists simply by our continued efforts. We quit and the hospital shuts down. You quit and we receive a few less emails. Neither you nor the very government that helps create the very dictates you so enjoy enforcing can make us work. The truth is that we have the final say on everything. The truth is we do not need to hate our existence. But the truth is also that we are too cowardly and ignorant to appreciate this fact. This is why you and your kind have been able to usurp all your power. But no more. We are done.

“I don’t –”

“Go back to your superiors. Tell them we are not doing anything more than what is appropriate for patient care. If they appear to be under the impression they control us, tell them we will leave. All of us. If they question our resolve, I would inform them that there will be no further warning shots. We desire to practice medicine but not in these conditions.

“Is this really what everyone wants? Does he speak for everyone else here?”

*heads nod*

“Now, please, run along. And thank you for lunch.”

 

 

It’s fun to dream.

Image

Image is everything. This is one of the fundamental governing principles of our current society propagated by our collective narcissism and ignorance. Reality is irrelevant. Truth is irrelevant. The only thing that matters is how carefully one can construct their image that casts them in the most favorable light. People spend hours perfecting their selfies, timing their posts for maximal viewing, and openly identifying with subjects that best represent how they feel they want to be viewed. One only need to browse Twitter, Instagram, Snapchat, Facebook, or take a time machine back to the early 2000s and find a Myspace account to fully appreciate the fact that we prefer our Matrix constructs over our IRL alternatives. I imagine many would view these self-constructed echo chambers as benign. The assumption being that those who are doing “important” things are not equally engrossed in this triviality. However, assumptions are bad when those making them are clueless. And they are dangerous when the subject of those assumptions believes in them.

Just look at medicine.

Physicians serve as a quintessential example of what many would classify as “people doing important work”. Most would like to believe that the decisions physicians arrive to and the actions they take are driven by objective facts derived from an objective reality. Physicians are rational beings with years of training and practice. They are superior beings capable of accurately weighing all options and assessing all scenarios in order to formulate an appropriate treatment plan. They are Mommy AND Daddy. This is the first lie.

Physicians are not perfect. Many physicians may not even be competent. But that truth, that objective reality, is not pleasant or comforting. Quality is assumed not because we are trusting but because we are fearful; our parents are perfect until a judge says otherwise. Perfection is a hard standard to meet and this image of physician perfection was not constructed by physicians but by patients. Even in an age where you can find any number of stories about physicians doing dumb and corrupt things, the expectation of excellence is still there; no one intends to see Dr. Just Barely. Despite this being a childish expectation, many patients can’t be faulted for maintaining it. The practice of medicine is equivalent to voodoo crossed with applied physics in the minds of most patients. They know there has to be something to it but it all still looks like hand waving and jibberish. This image becomes nothing more than a defense mechanism against anxiety which ends up being directly proportional to physician pedestal height. And as protective at this image may be for some patients, it is equally toxic to the physicians of interest. Perfection is a high bar and most physicians would prefer to not make that jump if only because many who try often end up at the bottom of a tall building.

“So patients are to blame for everything?! Doctors are blameless?”

Not hardly. We may not have created the image but we don’t do much to refute it either. It is ingratiating and we are cowards. Many of us secretly enjoy the feeling of perceived superiority no matter the consequences. It’s the closest thing to power most of us will ever get to experience. It also serves as the gateway for our own delusions involving patient care.

When it comes to patient care, physicians make a lot of decisions. Most physicians believe that the decisions they make are based off information acquired from high quality clinical trials and supported by official recommendations from medical organizations represented by an alphabet soup of abbreviations. The ACC/AHA, AMA, AFP, ACP, USPSTF, ACOG, AGA, ADA, APA, and IDK must know something! Never mind the fact that most guidelines are frequently based off “expert opinion”, that most experts cannot agree on anything, that most studies exclude large portions of patients with medically relevant co-morbidities, or that IDK is not even a medical organization. None of that is relevant. The only relevant part is that there are groups of wizards behind curtains conjuring forth guidelines, misinterpreted as mandates, that ensure appropriate patient care and positive outcomes. In an attempt to be more succinct, patient care is driven not necessarily by what is right or wrong but by what many physicians view as the image of appropriate treatment.

“But that’s the standard of care! Are you advocating that we not provide standard care for all of our patients?! What if there was a bad outcome? How would you defend yourself then?!”

That’s the visceral response programmed into all of us when confronted with guideline dissent. It’s a response generated partially by fear and deference to authority and maintained by our own delusions. We need to believe that what we are doing is correct. We need to believe that we are doing the “right” thing and not simply following arbitrary rules or practices because we know what is best for the patient. We strive to project the image of good care even if that care turns out to be harmful. One only need to take a close look at the protocols for Surviving Sepsis and the consequences associated with iatrogenic salt water drowning. Despite objective evidence telling us otherwise, it is still common practice to flood the septic patient with ungodly amounts of fluid and then pat ourselves on the shoulder when they are intubated for pulmonary edema. “But we did everything by the book!” Can’t argue with that. But that doesn’t make it right. “I don’t get it.” I know.

This concept that “Image is Everything” is so deeply ingrained in medicine at this point that I doubt many people even see it. Or worse, I doubt many even see a problem with it. “Doesn’t it serve as a means of improving compliance?” Well, yes, but that’s the problem. Compliance seems to always be the goal. What does it say about a group of people whose only goal in life is to be compliant? Or better yet, to view the perception of compliance as the main objective? How deep will we travel down this hole and with what tools are we willing to use to maintain this folie simultanée?

 

I imagine if anyone in the medical field read this they may vehemently reject the entire premise. I get it. It’s difficult to face such an unflattering reality. It’s much easier to continue in a state of ignorance focusing on the optics instead of the outcomes. After all, this is America! But at some point, we will need to determine what is more important. Do we value the practice of medicine or do we value the image of practicing medicine?

And how does that look?

The Problem with Altruism

Altruism is killing us. Take a second to let that sink in. Truly think about it. Resist your conditioning to refute this claim and try to apply it to your life. Still having trouble? Let me try to explain.

In order to understand the truly destructive force of altruism on medicine, one must first define altruism. This can be difficult to do in the United States as any “good” or “charitable” act will instantly be defined and praised as altruism but this is incorrect. Altruism is the complete devotion to the welfare of others at the expense and disregard of oneself. Try not to gloss over this last part, it’s important. Altruism is not providing gifts to loved ones because you care about them. It is not volunteering at a soup kitchen during your free time as a resume builder. It is not providing care to patients during working business hours or spending an extra ten minutes on the phone getting their medications approved. It is not performing a task in which you receive some benefit whether it be tangible or intangible. Altruism is the sacrifice of the self in devotion to the other. It is eliminating your vacation to see more patients. It is spending time away from family to answer pages and phone calls when you would otherwise be allowed to rest and relax. It is the uplifting of those that do not care about you to the detriment of those that still do. It is the systematic voiding of the individual that somehow ingrained itself so deeply in the field of medicine that many accept it as a core element to the practice of medicine. This is lethal.

Medicine has changed dramatically over the last thirty years. The Norman Rockwell days are gone and Big Business is here to stay. While the M.B.As have adapted rather nicely to the changing landscape, creating large networks of hospitals, clinics, and administrative overlords, the M.Ds have failed to adapt. We strive to care for our patients despite all else. We try and hold true to the teachings of those that came before us and blindly accept that altruism is essential to our craft as it was to our predecessors. The overlords understand this with complete clarity and are more than happy to walk us down the road to Hell with our good intentions. This is why your clinic roster dictates that you see twenty patients in a day, why you are hounded by “documentation specialist” on whether something is “acute or chronic”, why you are expected to complete CMEs and MOCs, why Press-Ganey demands nines or tens, why your salary goes down while your RVU requirement goes up, and why you spend most of your day interacting with a light bulb trying to figure out how it came to this point. And if there is ever an open disagreement about adhering to “the rules”, altruism is invoked by the phrase “for the patient” to stifle further unrest. Because with altruism, if it’s “for the patient” there can be no valid counter-argument that contains the phrase “for the physician”.

And what effect does all of this have? Is anyone truly perplexed that the suicide rate for physicians is over double the general population? Is anyone truly astonished that physicians are burnt out and desperately seeking the sweet release of retirement or career change? You cannot take a group of highly motivated individuals, set an unachievable goal with unrealistic expectations, and expect a large majority to not fall apart. You cannot expect those highly motivated individuals, who start seeing themselves only in the light of failure, to see much benefit in continuing their existence for decades in such a state. I am not condoning their actions but I am not ignorant to their perception of reality. And I cannot stress enough that this constructed reality has been largely fostered by the core value of altruism.

Altruism does not make you a good person. It does not make you a moral or ethical person. It does not help you take care of patients. Whatever benefit altruism may have provided in the past, it has long since passed and now serves as nothing but the anchor around our necks threatening to drown us. We have to accept that we have value, that we matter, and that we are an end unto ourselves. We have to accept that altruism is a burden and not a blessing and excise it from our core. We can still be physicians without it but we may not be physicians for long with it.

There is no Fight

The large majority of what I do, day in and day out, is tend to and treat the critically ill. I work primarily in the intensive care unit because I prefer my patients ventilated and not talking, but I also prefer to deal with real medical problems as opposed to the chronic abdominal pain epidemic found on the floors. And although I do enjoy the intensity of critical care, the procedures involved, and the problems encountered, I do find myself rather frustrated with the overall trend of critical care patients. To be more specific, I am tired of continuing with heroic efforts to save those that are well past their expected life spans.

It is a common complaint throughout the health care field. Nearly every physician that works in a critical care setting, and even those that primarily work on the floors, cringe at the idea of aggressive care for the severely debilitated octogenarian. We wring our hands every time a family elects to send grandma to the ICU, complain among ourselves how futile the situation is, reaffirm our own desires to never have any of this happen to ourselves, but ultimately still treat the patient with the family none the wiser. This torturous charade of “life-saving” care drags on, sometimes for weeks, and ends in only one of two ways: long term nursing care +/- tracheostomy/feeding tube or death. There is no happy ending. This is American healthcare dollars at work!

“Wow! That sounds hella’ depressing! Why do we do this if outcomes are so bad?!”

Excellent question, person-who-has-clearly-never-interacted-with-Americans-before! I got two big reasons for you.

Baby Boomers

The first and foremost explanation for the above scenarios has to do primarily with the fact that this country is becoming older, sicker, and increasingly unrealistic. The Greatest Generation is nearly dead and they are being followed by their exquisitely narcissistic off-spring known as the Baby Boomers.

The Baby Boomers, until recently, were the largest generation of Americans in existence. They were born around 1946-1964 and were the result of post-WWII blue balls coupled with raging prosperity. Their parents, who suffered through economic devastation prior, were hyper-focused on providing their off-spring everything they needed to succeed in this post-war boon. Good intentions abounded for this generation. They had everything. And what did they do with it? They squandered it.

The Boomers are notorious for their collective narcissistic traits and their limited insight. Unlike most generations, they seem to be focused primarily on the present, specifically their own. Despite having children and proceeding through the game known as “Life”, the Boomers have refused to give up their petulant desire for instant gratification even at the cost of the future (see: President Trump). There are several articles and books which delve into this topic. Most of these will miss the point in some way. If anyone wants a legitimate interpretation of our current cultural crisis, I would recommend listening to a drunk psychiatrist. There is a lot to process in all of that, so I will leave further elaborations to the experts. But given the above, the relevant question becomes “What happens when a narcissist nears death?”.

They fight.

Or at least, they construct a narrative in which they believe there is a fight that can be won despite the obvious truths regarding their impending mortality.

Let me explain.

There is a common narrative among many Boomers that find themselves on the unfortunate end of an unfavorable diagnosis. The narrative is that this diagnosis (usually cancer) is simply an obstacle to overcome regardless of the fact that it may be metastatic, recurrent, or has failed two rounds of treatment and is rapidly spreading. “We ended Vietnam! We accomplished Civil Rights! We brought down Russia! We can do anything!” is the mantra I envision in their minds, coupled with the Rocky theme, that echoes in the background of a pre-constructed montage set to max volume in order to drown out the harsh reality that their movie is coming to an end. There is rarely any acceptance of the inevitable because they cannot conceive of an “inevitable”. They cannot conceive of a movie without its protagonist and they cannot conceive of any existence where they are not the main lead. Rick Grimes can’t die! The end result of this is not a heroic recovery in the face of all odds with Michael Bay background explosions and epic orchestral music booming; the end result is a prolonged death in an intensive care unit often punctuated by rib-crushing rounds of CPR or withdrawal of care after extensive family discussions regarding the overall futility. And no, the patients rarely ever tell the family what they actually want in this situation outside of “do everything”. This is why the last month of life seems to be so expensive.

This extends much farther than just “end of life” care though. Given that the Boomers have been unable to be future-oriented for the entirety of their lives, the results of that present-oriented thinking are coming to light. It is no secret that more and more people are developing chronic illnesses and the truth is that most of these chronic illnesses are preventable. Or should I say, they were preventable. A lifetime of smoking, poor eating, no exercise, and recreational drug use has led to COPD, heart disease, heart failure, diabetes, high cholesterol, hypertension, and chronic hepatitis. All of these are treatable, some are curable, but it takes effort and compliance. There is a large number of patients in the Boomer population that refuse to take their medications, down-play their medical problems, or subscribe to the belief that the medical-industrial complex is in bed with the Illuminati to propagate disease in order to profit from sham treatments provided by the greedy physicians. It is this propensity towards conspiracy theories which has helped launch the anti-vax, alkaline, naturopathic, hormone craze  which seems to be spreading among the over-educated.

The end result of this childish ignorance is always the same. It ends in disaster. Their disease invariably progresses, they find themselves hospitalized with increasing frequency, their frustrations build over their inability to get better, they begin to blame physicians more for “not fixing them”, and it eventually ends where all great American stories end: the ICU. And just as above, they fixate on the idea that they are “fighting”. Their families continue to proclaim that they are “fighters”. No one seems to understand that 1) this is not a fight, it’s a beating and 2) the only thing that was being fought was reality and reality always wins.

Physicians

The medical community as a whole is horrible at delivering bad news. There is a reason that there are workshops dedicated to this, both for residents and full-fledged attendings, and why palliative medicine exists. Instead of accepting the reality of the situation, many physicians elect to walk down the road of willful ignorance hand in hand with their patient hoping for a cure via their “treatments”. This fantasy construct is best exemplified in the field of oncology.

Oncology is a field defined by the fact that nearly all of their patients are moribund faster than most other. This makes it an intrinsically difficult specialty. Unlike years past, when most people died relatively quickly from their disease due to limited treatments, this field has seen an explosion in research. There are multiple treatment lines for nearly every oncologic condition. In addition to the standard chemotherapy, there are therapies targeting specific receptors and signaling pathways which appear to have fewer side effects, potentially greater efficacy, but also higher cost. This means that those imminently terminal patients from the past are living for years instead of weeks. This also means that the relationship between the patient and physician becomes more complicated. The oncologist becomes familiar with their patient, their families, and is often involved in every complication involved with both their treatment and disease. The oncologist becomes the primary care physician. This benefits no one.

Excluding certain hematologic malignancies and immediately excisable solid tumors, cancer always progresses; cancer always wins. The oncologist knows this although many will refuse to openly accept that fact. Their ability to accept that reality is further compromised as they start treating patients more like friends. This is never more obvious than when a cancer patient is admitted to the ICU and the oncologist wants to be involved in their care. It is a recurring theme that while their patient is intubated, in septic shock, with renal failure, and developing DIC, they will continue to tell the family that further treatment options can be considered once the patient has recovered from their “critical illness”. Never mind the fact that this “critical illness” is a consequence of their multiple treatment failures, deconditioning, and metastatic spread of their underlying cancer, they will present it to the family as unrelated. They continue to provide hope for the family and the family holds fast to this hope. This will go on for days, weeks, even months. Maybe the patient leaves the ICU, maybe they leave the hospital, but the patient is never well enough to be a candidate for further treatment. There is always another unrealistic goal set which is invariably followed by several setbacks, repeat hospitalizations, treatment complications, deconditioning, and ultimately death. In other words, the patient is attached to the wagon of good-intentions and dragged down the road to Hell.

It is not easy giving bad news. There is no joy in it. And giving bad news to people that you have come to build a relationship with over a span of months to years, to people who may send you holiday cards or bring in cookies to the office, is even harder. It is the equivalent of giving bad news to your grandmother. It is easy to ignore reality, to focus on “potential”, and to give words of encouragement and hope. It is easy to buy into the pervasive myth in medicine that families are only open to receiving optimistic news. It is easy to watch the wagon be pulled down the road while you shout words of encouragement from afar. It is easy to be a coward.

Death and dying is a large part of my day in the critical care setting. I give bad news to families all the time. In some ways, it has become almost routine. It requires a degree of emotional intelligence, as some are more open to harsh realities than others, but I have found that every family is thankful for candid conversations. I have had many families comment that no one had been direct with them before, that they felt something was being excluded from past conversations, and that they wished prior physicians had been more direct regarding prognosis. I have never had a family become angry, violent, or demand transfer. I have never had “patient experience” get involved after delivering terrible news. I relay the information in rather black and white terms, limit the use of optimistically ambiguous terms (maybe, possibly, hopefully), and often times offer my opinion regarding the situation if the family is interested. Despite the medical communities push to destroy every vestige of paternalism, many families are comforted by physician recommendations against leaving their eighty-year-old father on life-support indefinitely. Sadly though, too many physicians are unwilling to have these candid conversations, due to their own discomfort, and the cycle continues until the wheels fall off.

 

These are not the only reasons for the perpetuation of futile care. There is a myriad of factors. But generational narcissism and physician cowardice are two of the dominant factors. The former can only be cured by tincture of time, but the latter can be improved upon today. Because whether or not physicians want to have the conversation, it will need to happen. We can decide to have it on our own terms or we can wait for the government to indirectly force our hand.

The fight will end somehow.

Medical Competency: An Unfortunate Truth

There is an unspoken truth throughout the medical field. It affects every specialty of medicine along with every hospital; nowhere is immune. This truth? It’s that not all doctors are competent.

“What?! But they passed boards! They went to school! They are supposed to be smart! How do you know which one? OMG should I go naturopathic?”

It is a fact that every practicing physician in the United States has completed the conditioning program known as medical school, jumped through the hoops known as their “Steps”, managed through their existential crisis known as residency, and then topped it off with their boards to finally reach the status of full-fledged pill dispenser / knife jockey. It is also true that all of these people are undoubtedly smarter than your high school friends who were unable to read a paragraph aloud in under five minutes. But none of this equates to that physician being competent.

“So why are they incompetent?”

Well, I’m glad you asked, voice-in-my-head. Let me try to explain.

Lack of Appeal

First and foremost, one of the biggest issues with maintaining a competent physician work force is to recruit people who are actually capable of being competent. It is an understatement to say that the medical profession has an “image problem”. Physician suicide remains high, the reasons for which remain vast and ever-increasing, satisfaction with career choice is poor, and the large majority of our time consists of paperwork and other bureaucratic bullshit. I remember when I was a pre-med student and shadowing a family physician in my home town. I remember, in between his morning and afternoon clinic blocks, him rushing to eat lunch in his office, checking his own blood pressure, and asking me if I really wanted to pursue a career in the slow-death known as the medical profession. I remember answering in the affirmative, willfully ignorant to the obvious, and naively hopeful that not all of medicine was like this. The joke was on me, I guess. I know for a fact that many, if not the majority of, physicians would not recommend going down this road. Many of our recommendations go unheeded, often for the same reasons we ignored prior pleas, but I get the sense that is changing.

Despite the ever-increasing number of boxes that require checking and hoops necessitating jumping for medical school admissions, I would wager that the overall quality of medical student is degrading. I do not mean that the scores are dropping or the academic focus is fading. In fact, I would argue that the requirements for medical school continue to become more stringent. But I would argue that the “well-balanced” medical student is becoming a thing of the past. At least anecdotally, I have noticed that the ability for critical thinking, deductive reasoning, intellectual flexibility, conversational fluency, perspective, and the ability to “read” people have been severely deficient in many medical students. Conditioned to be nothing more than high-scoring automatons willing to consume and regurgitate specific sets of data repeatedly over a span of years, I understand how their other faculties could suffer. But it also seems that most medical schools are purposefully selecting for those individuals who are most adept at generating high board scores usually at the cost of social intelligence. To put it into primetime TV terms, medical schools are searching for The Good Doctor .

“But The Good Doctor is super smart and saves people all the time! He’s like so amazing!”

Sure, if I ever had a TV-medical problem I may be inclined to put him on the case since House is no longer available. But this is not TV. Medicine is rarely curative and I am willing to bet you would be unable to last ten minutes conversing with someone of similar social deficiencies before clawing your eyes out. Furthermore, the intellectual rigidity most often associated with the real-life proxies of The Good Doctor make them at best questionably hygienic encyclopedias. But, if medical school admission committees get their way, you may have no other choice. Everyone else, equally intelligent but able to maintain eye contact, has already heeded the advice of their depressed and possibly medicated predecessors and veered away from the medical profession.

Lack of Thought

There appears to be a paucity of critical thinking throughout the medical profession. To be clear, research is still on-going, new treatments for diseases (primarily cancer) are being manufactured, and academia is still thriving. But all of that is largely irrelevant to the patient sitting in the waiting room; the big question is whether or not your clinician is still capable of critical thought.

There is a lot to know in medicine these days. And outside of “The Good Doctor” and “Dr. House”, it is unlikely that any physician will know it all. And even if they did, it would be irrelevant within five years. With this deluge of knowledge, the cult of Evidence-Based Medicine (EBM) was conjured forth into existence. Like all cults, EBM promised real answers to troubling questions; it promised to apply scientific knowledge (trial data) to the problems of our times in order to ascertain the best treatment option. No longer would we need to live in the dark ages of “expert opinion”; we were bound for enlightenment! But sadly, like most cults, it generated more confusion than clarity and focused on control of information but without the benefit of crazy sex parties.

Through the utilization of EBM, hundreds if not thousands of guidelines were generated spanning nearly every medical problem in existence scattered throughout hundreds of different journals and medical societies. What once was supposed to serve as a guideline for practitioners, presumably based off trial data (but more often still based off expert opinion), slowly morphed into a mandatory “standard of care”. Never mind the fact that not all trials study all patients afflicted with a specific disease. If you have Disease A then you better get treatment X or risk possible malpractice. Praise be to EBM!

I imagine it was this development, along with several others, that led to further specialist referrals. Problems that once may have been managed by a primary care doctor were now referred out because it was impossible to keep up with the ever-changing recommendations by the “Powers-That-Be” for each group of specialists.

Following this even further, the only way to effectively treat a patient now would to become a specialist. Yeah, you could still work in primary care, but no one wants to do that anymore. It’s way too much work. Instead, you should specialize and get the privilege of focusing on a specific area of the body. However, now that specific area of the body has about ten different medical advisory groups, each focused on their unique disease, and each with their own body of recommendations which can span hundreds of pages long. Shit. What do? I know! Sub-specialize! Now you can focus primarily on diseases affecting the lower third left ventricle of the heart, be an expert on relevant recommendations, and never have to concern yourself with anything involving any other part of the body! And the best part? Templated notes ensuring that you never miss any detail needed for patient questioning or billing purposes.

This is why many Americans have the luxury of seeing eight different specialist a year for a handful of different problems, each specialist prescribing their own treatments, each specialist providing their own recommendations, and each specialist wholly ignorant to the workings of their colleagues. Occasionally, the primary care provider may be able to intervene, if they have the capabilities of doing so. But for the most part, the wheels of the machine continue to turn unabated until an inevitable complication lands the patient into the hospital. This allows the patient to see all of their specialists at once for a fun Battle Royale of competing ideas. Although each specialist is likely well-versed in their specific field, they have willfully abjugated themselves from the whole of medicine. Generalized competency is lost and so is the patient. But those boxes are checked!

Lack of Control

If it has not become obvious by now, physicians appear to have far less control over their occupation than they did in the past. As mentioned already, most of their work revolves around glorified secretarial work in order to prove their worth to their respective M.B.A overlords whose job is to quantify productivity and exert bureaucratic control. This is not to say that we do not deserve this treatment. We most certainly do. We gave up our control willingly to avoid the hassle of worrying about finances and other “non-medical” issues and in turn we allowed ourselves to be pushed into a pseudo-slavery propagated solely by our collective cowardice. Ask any physician, in private, about their thoughts regarding kicking the system down, striking, or refusing to comply to the insane regulatory requirements (IE: MOCs) and they will grab their pitchfork and torches. Suggest the same in a public setting, and be met with a collective brow raise, platitudes ending with “…for the patient”, and recommendations to instead appeal to our masters for more control over our lives which is invariably denied. Eventually, another physician will kill themselves in the interim and physician burnout will be the hot topic of the day. Victim blaming often ensues during these discussions which reinforces further to the physician that the system is here to stay and that the best they can do is try and learn yoga. It is usually easier just to keep drinking until the next cycle begins though. This happens ad nauseam to the point where the medical community as a whole would be viewed as having poor insight and judgement during a psychiatric exam. Again, this is why so many physicians want out of the field and are slated to be replaced by the box-clicking, questionably autistic, automatons currently matriculating through our medical schools.

 

I’m not a genius by any stretch of the imagination. I highly doubt I will ever change the face of medical knowledge. But I can at least see that which is in front of me. This is why I have a hard time interacting with my “peers” without openly questioning their sanity. This is why “outside hospital” sends me patients that are billed as “too complex” because they have three or more chronic conditions and the transferring physician has no idea how to logically approach it. This is why I have to dictate to may different outside ED physicians how to appropriately evaluate a patient on BiPAP to determine if they need to be intubated. It is scary just how many physicians in critical care settings don’t get it. This is why cases of iatrogenic salt water drownings are so common in hospitals that are hyper-focused on guideline driven protocols, such as for sepsis. Soon they plan to roll out a protocol to initiate antibiotics and fluids on patients who MIGHT be septic in my hospital. To the three people who may read this, and have no medical background, they want to give 2-3L of fluids to people who have no business getting fluid (heart failure, kidney failure, liver failure patients). This will invariably result in respiratory failure, further complications, and likely ICU transfer. So why do it? Because CMS has changed guidelines into mandates. Because bureaucrats and spreadsheet jockies are never challenged. Because critical thinking is irrelevant. And because competency is all but dead and the patients are not far behind.

“….So how do I determine if my doctor is competent?”

Trial and Error. Good luck!

Electronic Health Records

The creation and dissemination of electronic health records (EHRs) was inevitable the moment personal computers provided every household with unlimited access to porn. While everyone was enjoying themselves in the presence of nubile cyber nymphs, the Powers-That-Be were preparing for an all-out assault on every last sector of the planet that was operating without a keyboard. Today, as long as you appreciate running water and not shitting in public, you must comply with the internet. Medicine is no exception.

I.

EHRs started to become wide-spread in the medical field sometime in the early to mid-2000s with all the snake-oil promises that one would expect which included: reducing medical errors, making information available in order to reduce test duplication, and improving accuracy and clarity of medical charts. In the same way that Congress has no idea how the internet works (some believing it to be a series of tubes), the medical community and its self-appointed leaders clearly had no idea what they were doing or how to internet. They probably should have asked a Millennial. I’m sure any one of them could have quickly showed them the error of their ways with a simple cat meme. But alas, an expert was not consulted and here we are today, wringing our hands in protest of our new overseers.

For over a decade, physicians have been struggling with accepting the use of EHR. Many have expressed dissatisfaction over the fact that more than half their time is spent “interfacing” with a shiny rectangle instead of intently listening to their patient’s complaints which are likely centered around nebulous fibromyalgia pain. Some of the older physicians are even fantasizing about leaving medicine citing the increased burden of serving as a gloried data-entry monkey instead of a physician which is what they were originally trained to do. Furthermore, the promises of reducing errors have been found to be baseless  in that the alarms and alerts scattered about the EHR do nothing more than produce alarm fatigue with only minor improvements in care processes at best. I don’t care how many pop-ups you place in front of me, the foley is staying in.  Although, to be fair, it appears that prescribing errors have decreased some but only because each order starts with a default dose followed by a range of options which allows the physician to at least have a chance at guessing the right answer; we are only trained to excel with multiple choice exams. And as far as decreasing duplication of records, that has also been found to be a bogus claim. As of 2015, 60% of PCPs were unable to electronically exchange records with other physicians outside of their practice. This is not limited to the outpatient world. Anyone who has spent any time in the inpatient setting trying to obtain records from an outlying facility is usually shit out of luck, except for in larger cities where different institutions may have the same EHR and thus are able to share some limited records. This is less that information sharing is streamlined and more a gradual monopolization of information by a superior EHR system (read: Epic). Trying to get records from an outlying transferring facility that does not have the same EHR? Good luck! I can’t tell you how many records I received either by fax or transferring medic which were still hand-written and illegible. HAND WRITTEN! And that is assuming they even send records of any remote importance. Most transferring facilities seem to believe that nursing notes and skin assessments are all that is needed.

But despite all of these problems, the fact that research has continually debunked the promises of EHRs and that many physicians would prefer to slam their dick in a sliding glass door than interact with their institution’s medical record system, they are still being touted as necessary to patient safety and improved care. Although reality is quickly becoming irrelevant (see: Presidential Election 2016), it is still fascinating and horrifying that despite very clear evidence to the contrary, the zealots of EHR refuse to acknowledge the fact that they were wrong; they were wrong about everything. None of their promises have been fulfilled but I suspect that none of their promises were ever meant to be. Hindsight is 20/20 but realization is a bitch. EHR’s were never meant to improve the lives of patients or physicians; they were meant for control.

II.

Back in the day, during a simpler time in medicine where medications were limited and payment could consist of eggs and a chicken, physician notes were meant for no one but themselves. There was little order to how they were written and legibility was only relevant to the person writing the note. SOAP notes did not exist. Best practices did not exist. Medication reconciliation and a full review of systems did not exist. Often times, a few simply lines would be all that was written as documentation for a full clinic visit. This took a few minutes. It was likely the least consequential part of being a physician. Those lucky bastards.

Fast forward 30-50 years, with the advent and dissemination of the SOAP note, and the landscape has changed. The notes are still paper, as Big Internet had not come into the picture yet, but the format was drastically changed. In some ways, the change was for the better. There was more structure provided, it required at least some relevant information for those that may be exposed to the notes and were not the author, and one could create pre-printed templates to help expedite the process. But more importantly, this change allowed the implementation and utilization of EM codes. Physician’s had to prove their worth by writing down their thoughts as well as important aspects of the patient encounter and then code accordingly based off the complexity of the encounter. This form of note writing did end up taking more time but it was not overly burdensome. Physicians could still enjoy being physicians.

Now bring it to the present, for the last twenty years or so, and the landscape has changed once again. Big Internet kicked down the door, flexed nuts, and opened a portal from Hell to fill the land with endless Best Practice Advisory pop ups, guideline reminders, data element requirements, check boxes, and ICD codes. With the implementation of EHRs throughout the land, the task of billing and note writing which was once considered an inconvenience, has become the tools of our enslavement. What once use to consist of no more than a page in short-hand has now morphed into a 4-7 page, primarily auto-populated and copied forward, irrelevant gargantuan ever evolving to demand more data without providing any useful information. Per usual, the outside influences were far more intelligent than the whole field of physicians. The insurance companies, and specifically Medicare and Medicaid, saw the opportunity that the electronic age provided for demanding more and giving less. They also seemed to understand the cowardice of the physician population and took special notice of the fact that their training made them particularly susceptible to achievement-oriented enslavement. With this knowledge, and the weaponry known as The Affordable Care Act, an all- out assault on the medical field was launched.

Notes were scrutinized with ever more arbitrary elements required to obtain a certain level of billing, the calculation of which was purposefully made difficult in an effort to then fine and demand repayment for the inevitable misbilling of encounters. Requirements regarding obtaining a “full” review of systems, despite the complete lack of evidence this provides any useful information, a family history, social history, and a complete medication list (despite the fact that NO ONE knows what they put into their mouth) were required for every note in every encounter, especially in the outpatient setting. Particular language regarding diagnosis and timing of diagnosis were established, and frequently changed, in order to deny payments for mislabeled diagnoses or for missing diagnoses of questionable importance at the time (IE: Obesity). This assault has been further augmented by the requirement of physicians to register with several different physician review organizations, often requiring renewal of registration every few months, with penalties for those who forget or have better things to do (like finish those God-damn notes). And lastly, as if to add insult to injury, the Powers That Be have felt the need to make sure one cannot successfully navigate through their EHR without suffering through no less than 5 pop ups demanding attention to several, often times inconsequential, elements of a patient’s care. (No, I am not going to order a flu vaccine. It’s May. Fuck off!)

It’s all about control. None of this is for the patient. None of this is for the physicians, in as much as it improves their lives or makes their job easier. It is all to control and bewilder those that have the real power. Keep them focused, keep their heads down, do not let them look up, do not let them get comfortable, change the rules, add more tasks, and never let up. This is their game and it works! Instead of requiring change, instead of saying “No”, instead of fighting back, we slouch down and continue with the grind. Occasionally, we like to use our “science” to make a point, but that never does any good. (Remember all the studies about how patient satisfaction is bullshit?) Science will not change the minds of those with an agenda. The assumption when studies are published is that the minds they are meant to change are ignorant to the fact presented; the fact is we are ignorant to their agenda. We are also ignorant to the fact that when we prove a system is flawed and then do nothing to change it, we are helping our oppressors. We may feel smug in our knowledge that the policies are bullshit, but the overlords already know that and we are still following them. “We got them good! Now I better get back to clicking boxes or Master gonna be upset!”.

Someday, after alcoholism and suicide has ravaged the medical profession, assuming the world has not ended in nuclear disaster or an Idiocracy-style decay, the medical field will make a change. The oppressor will be identified and de-throned. When that day will come, I have no idea. And what the profession of medicine will look like at that time is unclear. But I can assure you that if the change is not made fast enough, and while enough intelligent people still want to invest their life into it, we will be in trouble.

But in the meantime, those boxes aren’t going to click themselves.

Us-Versus-Them

There is a weird dynamic that occurs in nearly every hospital setting around the country. It’s a hostile dynamic that seems to be older than time and almost hard-wired into everyone that partakes in this seemingly fruitless endeavor known as health care. It’s an Us-versus-Them dynamic which oddly enough seems to pit physicians against nurses.

“That doesn’t make sense. Aren’t they supposed to work together?”

Indeed.

I.

The tension is immediately palpable upon your first day of third year clerkships as a medical student. If you think back hard enough, maybe you can remember the first time you walked unto the floors, asked a nurse a question, and were met with either indifference or resentment. The interaction may have surprised you. It was just a routine question, wasn’t it? Maybe the nurse was having a bad day? Regardless, you continue to solider through in your ignorance while nervously seeing patients and hoping to not make an ass of yourself in front of the attending. However, inevitably, you must approach the nurses again to ask about/for something. You proceed in your seemingly mundane and innocent task but ultimately are still left with the impression that you serve no purpose but to be a pain in their collective asses. Occasionally, you will have interactions with the nurses that are pleasant. Just as there are a handful of surgery residents who do not harbor bitter resentment and rage towards every living thing, there are also nurses who make it a point to interact with the “lessers” as if they were human beings.  These interactions are few and far between though. By the end of your fourth year, you have a clear understanding of how things work; you know which train tracks not to cross. And this is just in time for you to begin your residency where you get to see things from a whole new perspective.

Intern year is where you begin to clearly see the divide. At this point in your medical career, you effectively know a lot about nothing. And the nurses know this. At this stage, you are going to screw up, a lot. Like, a lot a lot. You are going to be too conservative in some matters and then too liberal in others. You are going to hedge when talking with family members and give too much hope when there is none to be had. You are going to contradict the nurse, even if you do not intend too, and create tension. The nurses expect this. They have been through it all before. Some nurses may even be able to do your job better than you. But still, and despite this, they are obligated to follow whatever you haphazardly put into the chart; it is a life of Groundhog’s Day just with different actors. They may call you about it, clearly annoyed, and demand you fix it. Or other, more subversive, nurses will follow the order to the T. At this point, animosity often arises and becomes rather obvious even to the dimmest of bulbs. And how do the nurses best convey their frustrations? It’s not by direct confrontation; that is a big No-No as many nurses have often been burned in the past for these types of actions. Their weapon of choice: passive-aggression.

You know it when you see it, the nurses that have taken up their passive-aggressive arms. You will receive a thousand pages for stool softeners, electrolyte replacements, diet orders, Tylenol, anti-emetics, and narcotics. You will never be called doctor; in their eyes, you are a baby doctor that barely knows how to crawl and is always covered in shit. They will interrupt you on rounds to give “updates” that contradict the information you obtained, they will question every decision you make, and they often will “go up the chain” when they disagree with you until they get an answer they like. And they will do this all in the name of “patient advocacy” because it is the ultimate trump card; it is the equivalent of invoking God’s Will as the reason for your actions. And as this goes on, as the pages piles up, and as the years tick by, things may get a little better. Eventually, you become the senior resident and no longer have to field the majority of pages, you are not presenting during rounds, and you are officially higher up on that “chain” where you can have a final say. But the memory of the past still haunts you, it still leaves a bitter taste in your mouth. Again, there were nurses along the way that were decent, amiable, and easy to interact with, but their light has been extinguished by the mounds of shit which was otherwise known as your day-to-day. And as you near the end of your indentured servitude, filled with the ugly memories of your war days, you hold on to that world-view of “Us-versus-Them” as you transition into becoming the illustrious Attending.

As an attending, you are now addressed as “Doctor”. Much of the overt rudeness you may have experienced as a resident appears to have quickly disappeared. You are at least given the impression of having more respect. And right or wrong, sometimes you may even feel like you earned it, so now you make your move. When you receive a page or call from nursing regarding a less than pressing matter, you lash out, belittle, or demand further information and a call back before hanging up. You demand to be called “Doctor”. You have little or no regard for how the timing or placement of your orders may inconvenience the nursing staff and may even erupt in a fit of indignation when something was not done perfectly the first time. And the best part? Despite occasionally acting like an impetuous child, no one will call you on it. You are the boss! Absolute power corrupts absolutely.

But despite the fact that the nurses may not outright call you a flaming dick bag to your face, they sure as hell are seething about it when you are nowhere to be found. They hate how you respond to requests for orders or information, despite the fact that it is their job to make such requests. They brace for impact when they see your name on the chart and have likely bitched to various supervisors which ultimately have no power to make changes. They will likely still use their tried and true method of passive aggression on you, which will be irritating, but you are still in control. They know that. And they hate that. And that hatred, since it can’t be paid back, is paid forward. And the cycle continues.

II.

It may appear that I have put all of this on the nurses, that I have accused them of throwing the first stone. Let me assure you, I have not. I do not know if anyone will ever know who drew first blood in this seemingly endless war as this information is likely lost in time. If I had to wager a guess though, I would bet on the physicians as cause of the initial insult. Unlike the role of physician, residents have only been a fairly recent phenomenon. Back in “the day”, many physicians just did apprenticeships with anyone that would have them, regardless of any true credentials. There were no large, urban hospitals, health insurance reviews, M&M conferences, practice standards, malpractice, or even many legitimate treatments. Hell, nursing was not even a profession until the mid-1800s and seemingly in response to most nurses at the time being rowdy drunks and assholes. Seriously.  So taking this into account, I imagine that physicians may have had to be raging ass hats towards a certain percentage of the nursing staff to distract them from their gutter whiskey long enough to perform a task that could have potentially been life-saving. Or unwittingly tortuous. Back then, it was kind of hard to tell which it was. Assuming this to be correct, or close enough, this culture has seemingly persisted throughout the ages despite the unfortunate lack of alcohol and boxing matches currently allowed in modern hospitals. But now, the physicians are not just magically appearing “fully trained” and the nurses find themselves in a position of relative power during the physician’s formative years. Let the hazing begin!

But the origin of blame is not the point. Assigning blame in this eternal conflict only distracts from the more salient issue of why this system is even in place. What good comes from the perpetuation of the “Us-versus-Them” culture? Is it good for the patients? Is it good for the hospital? Answer: It’s good for the system.

III.

It’s all about control. As I have already elaborated on, you need to distract and demoralize those you intend to control in order to make them accept your command without question. This is especially true when the servants possess the power; you need to make sure they never use it. In our current system, the nurse resents the physician for built-in subservience and the physician resents the nurse because they seemingly make their job, and by extension, life more difficult. Both camps seem to be too caught up in the conveniently constructed struggle to notice that they have a mutual adversary: the patient.

It is no secret among the health care community that the vast majority of patients that are encountered in the hospital setting are nothing more than morbidly obese, cognitively impaired, adult-themed children that are hyper-focused on the irrelevant. These patients seek nothing more than narcotics and food and invariably complaint about both the speed in which they are acquired and the pleasure that is derived. I’ve had multiple patients come in unable to breath and demand a hamburger, mashed potatoes, and soda; I’ve offered them hospice with only a minimal amount of facetiousness. Sadly, they never take me up on it. Instead, they somehow find a way to survive their hospitalization with only a minimal number of aspiration events and are eventually released back into the wild to inevitably be re-admitted again.

These “patients” serve as the impetus for the eternal conflict. They are the initial reaction that sets off a cascade of events resulting in frustration. These are the patients that the nurse is constantly calling about narcotic orders, diet orders, non-compliance with treatment, need for frequent updates, and threats of leaving AMA. These are the patients that the doctor hears about ad-nauseam that lead to a full rage meter and broken pagers. It is these patients that serve as the kindling which ignites the fire that consumes any chance of decent working relationships. They are the central cog in the system’s design however their ignorance is so great that I doubt they even understand the role in which they play; the role of the unilateral rage generator.

No matter how horrible and ridiculous they may be, patients are untouchable, especially in this era of “Health care as Business” where they will soon be referred to solely as “customers”. Save for some likely isolated incidents, the nurses are not yelling back at the patients, they are not (rightfully) telling them to go fuck all the way off, and they are not refusing ridiculous requests. Similarly, most physicians will allow these patients to run right over them in an attempt to save time by avoiding conflict in the hopes of still obtaining that coveted “9 out of 10”. Sure, some of the really crazy ones get their Haldol levels replenished, but this is not the norm.

So, what happens with this rage? Well, as alluded to above, it bounces back and forth between the physician and nurses until all they can see is their respective disdain for each other. And this does not just happen once a day, this happens several times a day. The battle royale known as “physician vs nurse” is continually powered all to the delight of the system; we are nothing but dancing puppets.

But the system is not happy with just physicians and nurses pitted against each other. The system has set up redundant circuits of in-fighting. Have you ever seen the ICU and PCU nurses get along? Have you ever seen the PCU and general floor nurses get along? How about different physician subspecialties? One could answer “yes” to any of the above, but they could not truthfully claim that it is the norm.

IV.

Think about what could happen if physicians and nurses suddenly woke up one day and began to work together. What if we started to direct our energies away from tearing each other apart and instead focused those energies on demanding patient reform? What if those energies were directed towards the bureaucrats and administrators that set the arbitrary rules which seem to govern our lives? What if those frustrations and anger were directed towards the national health care debate in an attempt to bring to light the true issues which make health care expensive? What if instead of focusing on our own bickering when faced with irrational regulations, we simply provided a collective reply of “I prefer not to”?

But unfortunately, there are dilaudid orders to place and nurses to chew out. So I guess we’ll never know.