I am not comfortable.


One of my friends was lamenting last night (well it was night for me, probably the middle of his day) that he wasn’t happy with the patient care he was witnessing at work. I can sympathize with him on this because it drives me crazy when I see it at work too.

I cannot speak for my friend, but I can tell you why it bothers me when I see poor patient care. First, I come from a family of soldiers and laborers. Predating the Napoleonic wars, fighting, mining, and factory work is what my relatives did. It is what my father did, my mother did, and I somehow escaped through great effort and sacrifice. But I wasn’t always free. I have done my fair share of manual labor, and one thing I know is that laborers who need to work to live and feed their families need to maintain their productivity. That productivity comes in many forms. It comes in the stereotypical male family figure whom goes to work every day, ignoring pain and sickness in order to earn money for their family. It comes in the form of single or working moms who not only have to care for family, but also have to work to earn a living. It comes in the form of the stay at home moms who basically do whatever needs to be done to keep their family functioning. It may be the grandparents who in their waning years are baby-sitting, lending a hand to parents who both have to work.

These people rely on their healthcare providers. They trust the judgment of healthcare providers, holding in esteem the knowledge, ability, and altruism and in all respects putting themselves and their families in such care. They believe in all respects that what providers do for and to them is for their benefit. Whether you are a doctor or a paramedic or a nurse or some position I am too lazy to type up, you receive not only money, but a special reverence in the eyes of everyone from the heads of state to the most low paid laborer.

Believe it or not, healthcare is not about providers. It is about patients. It is not an industry where you come in and do your manual part and go home. It is not simply a technical set of behaviors. One of my good friends and former coworkers is a CT tech. This sounds like a very technical job, but it isn’t immune from the concerns of the healthcare provider. You see, she is the one advocating not to use this radiological machine for the convenience of a doctor, but for the benefit of the patient. It is her that makes sure nobody overlooked your metformin prescription or contrast allergy. It is her who gets into “discussions” with people above her pay-grade over patient safety. Why? Because she cares about people. It is perfectly within her power to come in and simply and mindlessly press buttons. But to her credit and that of her profession, she doesn’t. There are many like her too.

Myself and my colleagues, no matter what their position, are part of medicine, and we believe in our hearts in the values and the mission. We live it. We expect the same from our colleagues.

Another thing that makes it hard for me to stomach poor care is because I am a “lead from the front” sort of guy. I like to be the one getting my hands dirty. I see my role as the guy who can always be found in the trenches, not directing from afar. If you ask around, I am pretty good at what I do too. It is hard to watch people who are not so skilled or caring.

Yet another thing that bothers me, because it conflicts with not only my own experience, but the ideals of my colleagues is the idea of providers who feel or act like patients are a nuisance who interrupt their day from being “easy” which they view as their right and privilege. I try to prove everyday on every patient I earn what I have. I even tell people, most notably at the formal PhD dinner I had recently which seemed to stun everyone, “the patients I see today, do not care what I did for the patient yesterday, so every new patient, every new day, is the day I will be measured. A first place finish yesterday doesn’t count for anything today.”

I like to be elite. To play for the best teams, to be the best of the best. I consider it a great honor to be the one people call for help and get paid to do it. I am very proud that I have earned that not only in the suburb of 24,000 I am originally from, but everywhere in the entire world I have taken care of patients. I have no use for mediocrity. I recognize not everyone is or can be a champion, and I am happy to help and teach anyone, but regardless of knowledge or ability, I expect them to care. I expect them to at least aspire to my ideals. I have very little time or tolerance for those who don’t.

One of the replies to my friend’s rant about substandard patient care, there was a reply that stated “the outcome didn’t change.” I can see how people who try to imitate professionals without understanding can latch on to a quantifiable metric like this. But I submit it is not just the goal, but the process that matters too. Here are a few examples. I took care of a patient who had a perianal tear and abscess. (It gets lonely in the desert.)The desired outcome was to check for extension, sew up the tear, and to treat and prevent further infection. Certainly I could have had a nurse or medic hold this guy down while I did what I had to do. But he very much appreciated being sedated for it. I can only imagine local anesthetic might not be enough to have your torn asshole probed, scrubbed, and sewn up. Another example was evacuating patients with bilateral femur fractures. (Usually secondary to an explosion) They really appreciate pain relief while they lay in bed. But they really appreciate a little more before they are moved over uneven ground in a truck and manhandled into an aircraft. (Many times an aircraft not designed as an air ambulance) I certainly could reduce a dislocation or fracture without medicating people and the outcome would be the same. But I submit, especially with kids, it is the process that counts.

I will right out confess, I am not always comfortable doing things I have never done before or doing things I don’t feel very confident doing. But when help is not available, I always remember that the whole patient care event is not about me. Strangely enough, I have discovered the only way to become comfortable doing something is to do it.

Medical knowledge and practice changes over time. Why would it be acceptable for providers not to change with it? Why do they insist patients need to “take it”? Why do they believe their comfort and insecurities take precedence over patient care? Would they want the same for themselves or their family?

Several months ago I was discussing with a friend the difference in teaching approaches of emergency medicine. He comes from an environment where “emergency” providers are the best of the best because they have to earn the right to take care of emergencies by taking care of hundreds of non-emergencies first. This is diametrically opposed to how I was taught, which was “here are the keys to the truck and drug box, best of luck.” I was asked what I thought was better. At the time I was of the mind both have merit. But looking back, I would answer differently. I would say the way I was taught. Because you cannot do something the second time until you have done it the first. I have also discovered emergency is like surgery. You can train and talk about it all you want. You can practice the skills in a teaching non-threatening environment. But when the real deal is dealt, when the tool is in your hand, and you call and take responsibility for the plays, it is an entirely different experience, things become much less certain, and the only thing that prepares you for it or makes it easier is doing it again.

At that moment, it is not about you. But you are involved all the same.


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