Said my internal medicine teacher in medical school. (I can’t spell his last name) but total credit for the phrase to Dr. Robert.
Before I get to the heart of what I want to talk about, I need to add some background in order that my point of view can be better understood.
I grew up in emergency service. When other kids were out experimenting with alcohol, sex, drugs, and finding their identity in the world, I was at the fire department, which in the place I grew up in also provided emergency medical service. My goal was simple. I was going to be the best at what I did. The reasons that led me to this goal, stems from constantly being reminded in my youth that by fault of my birth, I would not live up to the resources I consumed. In retrospect I think it looks a lot like the motivation of young Olympians, so much so, that there is actually a psychological theory on “the Olympic mentality,” and when I read it, I found myself thinking, “that sounds kind of like me’ Later in my life I would go on to meet world champion level athletes in my daily activity and found great kinship being around people whose single-minded devotion was excellence in their craft.
While some young people discover gymnastics, ice skating, swimming, or some other athletic pursuit; I found the fire department. To say I was devoted would be an understatement. It was totally life consuming. Like many young people groomed for a field or profession, I missed out on a lot of things. Things I didn’t even know I was missing out on. What’s more, even if I was told, I would not have chosen differently.
But for the loss, there were many gains. Constantly being around older people, I was learning the skills they were learning in their part of life. How to inspect a house you were going to buy, how to determine the quality of an employer, the lessons of raising their kids. But I also learned skills and experiences that many people in their lives will never understand. The feeling of cartilage cracking when doing CPR on a dead person; the fear and joy witnessed at the beginning of life, the anger and sadness seen at the end, and whether it was building construction, hydraulics, operating rescue equipment, or emergency life support, I was acquiring those skills before I was old enough to drive. But aside from those physical skills, my constant proximity to leaders and officers had given me other skills too. The understanding of labor relations, public relations, media relations, system design and function, preplanning, budgeting, and a host of other organizational skills. I had even developed a sense of humor dark enough to joke with any ED nurse, doctor, or emergency provider. But the thing that I value the most perhaps, are the values I learned. Among them, that the mission is bigger and more important than any one person, than any one organization. That mission is simple. When help is called for, that call is answered.
While I certainly took the road less traveled in my career, and it is ongoing, it follows a constant pattern. To add more knowledge and skills to always be able to answer that call. So despite my different titles, locations, and even life experiences, every day is another chance to passionately do the voodoo that I do best on a bigger stage. From suburban Ohio, to around the world, I am not so much a title, but a way of life. So while I worry more about what I will do tomorrow and look at past accomplishments as yesterday’s news, I like to reflect on this blog. So that I can spend time dwelling on the not so simple parts of my experience.
Now enough of “my trip down amnesia lane,” as the Great Robin Williams once said. Let us get to it?
Yesterday was a hard day for me. I spent all night traveling, to arrive for work at 0745. While I had a great day, at the end of more than 36 hours of being functional, I was tired and hungry. I am not as young as I used to be, and I do require a bit more down time between acts of major physical exertion. So, I got my pizza and proceeded to eat and check my Facebook feed before going to sleep.
The number one post on my feed was from one of my earliest role models and later my friend. It was a post out of UK EMS with a picture of an ambulance with the phrase “you wouldn’t call the coast guard for falling in a puddle”.
What this post essentially said was: “We think we are only for emergencies as defined by what we think we want to do in our work. That we are better than the uneducated rabble we life-saving heroes look down on. So unless we feel you are deserving, don’t call us.” You can only imagine how that runs contra to the belief of every call for help is answered, no matter how insignificant. That may sound idealistic to many, but I can offer my loyal assurance, when you are the one making a call for help out of desperation, that call being answered changes your entire life. It is the very essence of altruism. To scoff at it, is in my mind, the ultimate blasphemy.
So I made my little public relations quip and I was out cold. Not enough hours later my phone rang. As I usually do I gauged how urgent I thought it was, and seeing the number, knowing the caller knew both how tired I was and my previous 48 hours, I answered it. Sure enough, it was a call for help. A person in the UK was experiencing a medical problem and couldn’t find a doctor open who would see him. While it wasn’t a serious problem as far as medical complaints go, it certainly is not something that is easily ignored until morning, simply because the symptoms do not permit rest, sleep, or concentration. So I offered my best advice, go to the store and get an OTC med called X. If it doesn’t work, call me back.
No further calls, mission accomplished. So after a few hours of sleep, I woke up still a bit miffed. A person from a country whose medical providers unsuccessfully tried to fuck me for not sucking up to their narcissistic egos could not be reached in a timely manner so said “patient” had to call me in a foreign country. I am pulling no punches, if anyone considers that great patient care or a great system, they are delusional. So I wondered…why didn’t this person just go to the A&E? Then it occurred to me… Because in A&E they wear flair (buttons) that say unless you are dying don’t come. They print smart ass slogans on their ambulances that say “you are beneath us, don’t call.” They have posters and billboards that essentially say “we are paid by your taxes, but we don’t want to help you.”
Now I was pissed. People who work less, less intensely, and get paid exponentially more than me are so unconcerned with their mission that the call for help had to be answered from a different country. By somebody they decided was not one of their good old boys. Nor do I want to be a good old boy in a club such as theirs.
I wonder if a Japanese doctor would commit ritual suicide over such a failure? I would seriously consider it a major failure if somebody had to call a foreign country because I didn’t measure up to the need. I wouldn’t kill myself, but I would certainly resolve to never have that happen again.
Of course my thoughts on this led to a Facebook argument. So let me lay it out again, not because I think it will change the mind of a capable and honorable antagonist, but because somebody sitting on the fence out there might make a good decision one day. Because a burnt out provider looking for a reason to carry on might read it and be rejuvenated. Because just maybe, somebody new might not make their value their own wants and desires, and realize theirs are actually no more important than that of their patients.
Here is a quote that I think sums up both the fire service and medicine nicely.
“Our department takes 1,120 calls every day. Do you know how many of the calls the public expects perfection on? 1,120. Nobody calls the fire department and says, ‘Send me two dumb-ass firemen in a pickup truck.’ In three minutes they want five brain-surgeon decathlon champions to come and solve all their problems.”
― John Eversole
It has been my experience that most doctors need to really read and understand this quote. While educated enough to understand that no system or person is perfect, many doctors it seems to me use that knowledge as an excuse rather than a metric to be reduced to the lowest possible number through constant improvement. I find it even more entertaining when they default to “acceptable losses” but then despite practicing out-dated paternalistic medicine, they then deny responsibility for them. I don’t remember being told in medical school, but I can attest that in both the fire service and the military, the person making decisions is always responsible for them. It is impossible to claim to be the authority but not responsible. That means every time a doctor decides “what is best” for the patient, they assume total responsibility for any negative outcomes. That would be the opposite of modern medical practice where patients decide on a range of informed options presented by a doctor, even if those options are between possible death and certain death.
Patients, especially those from Europe or very poor people from everywhere I have been, recognize the limits of their knowledge and the superior knowledge of doctors in particular. They do not understand medical systems or specialty roles. If I ask 99% of doctors the difference between a member of an engine company, truck company, or rescue company, many would not even recognize I was talking about roles in the US fire service. The same amount would not know the difference between the engineering, deck, operations, and weapons divisions in the Navies around the world. At least 75% of doctors I have met cannot define what a nurse is or what “nursing” as a profession is based on. Those are people they work with every day and are an absolutely indispensable part of patient care. Most of the time doctors just define nurses as a set of skills they perform, rather than a distinct education and philosophy. Maybe there should be a day in medical school where we talk about “and these are your coworkers”? But instead I suspect we will just continue with superficial lip service like “team mates” or some other bullshit buzzword. (In fairness, nurses are not immune to ignorance of their coworkers, but I am not talking about nursing behavior today). Patients don’t recognize gastroenterologists from nephrologists. Many don’t even recognize the difference between Internists and Surgeons. In their mind, as well as in some medical systems, doctors are doctors. They are expected to know the basics of all parts of medicine, whether they have been practicing for a day or decades, whether they are a cardiac surgeon who subspecializes in valve replacement or a general practitioner.
So why do doctors (and EMS providers) seem to believe patients simply “know” what specialist to self-refer to or precisely where to go get the treatment they need? I will point out the same doctors (right down to the person usually) get pissed off when a patient has self-researched their condition and not only knows more about it than the doctor, but actually knows the current treatment guidelines for it while the physician is 10, 15, or even 20 years out of date. Personally I find it quite ironic. What’s more In the Medical community world-wide, there seems tremendous reluctance, even resistance to modernizing the way medicine is provided as well as its specialties. In fact, doctors are moving more away from patient expectations than towards them. Then doctors fear and get angry when they refuse to change their behavior or mindset and the only recourse is for patients to sue them.
I know I take special aim at general practitioners for this. Mostly because I am the one who has to deal with the fallout, both medically as well as emotionally from the patients. In my view general practice is so out of date and out of touch, that I would rather see all patients go directly to the Emergency Department. Making medical diagnosis and decisions without the most minimum of diagnostics seems like guessing to me more than “skill.” Strangely enough, the last article I saw on Medscape on who and why doctors get sued stated some 40% of all doctors sued we primary care providers (the US doesn’t have “GPs” per se, but I will use the terms interchangeably.) Furthermore, the number 1 reason for being sued was misdiagnosis. Well that’s a no-brainer. No time, no labs, no radiology, and relying on the patient’s story, unless they work at a more modern organization. I have no sympathy either. This is 2017, blowing smoke up peoples asses’ is not acceptable. It is not acceptable to diagnose cancer without a biopsy. It is unacceptable to diagnose ovarian cancer based on tumor markers. Why? Because Gonorrhea elevates them too, and that is the difference between a major life altering surgery and an antibiotic. It is not acceptable to diagnose( or rule out) a myocardial infarction without an EKG and labs, even if your patient is complaining of crushing substernal chest pain radiating to the arm and jaw. Why is that? Because it changes treatment modalities. It could mean the difference between an emergent PCI and a referral to cardiology in the morning. Basic diagnostics such as morphology(with diff) and chemistry, should be the absolute minimum labs in any modern practice. Since it is clinically unreliable for even skilled orthopedists to diagnose a fracture from a strain or sprain without an X-ray, A primary care provider trying to do it should be totally unacceptable.
But I am not alone in my thoughts on this. Patients think so too. That is why the Emergency Department is the provider of first resort all over the civilized and developing world. Absolutely nobody is a better traffic cop directing patients to the proper healthcare pathway. (Disclaimer: while I have lots of emergency experience, I am not, nor do I ever want to be an emergency physician). Better still, since the ED is usually well equipped for “treat and street” or “treat and release” from everything from dental pain to a host of surgical procedures, this one stop shop is ideal from diagnostics to many treatments for patients who do not require further diagnostics or more intensive treatment. This essentially makes GPs a middleman. (Disclaimer again: I count at least 2 friends as GPs/PCPs, as well as a few former,) The value of a GP can be debated on certain metrics; I think both preventing ED visits as well as acting as a healthcare traffic cop are not those metrics, where the ED wins out hands down. I will offer that outpatient follow-up as well as managing chronic diseases which are not in an acute on chronic or decompensatory phase are the primary benefit. But with no exception, I am firmly entrenched in the position that the ED should always be the point of first contact and that no patient should ever be disuaded from using it as such. A GP/PCP should be referred to, where the possibility of acute presentation, urgent intervention, and satisfactory diagnostics have already been performed. In effect, the value of these providers is providing follow-up and long term management to those presenting at the ED in the modern world. The days of playing “survive until you can get an appointment” or “diagnosis roulette” ended in the 1980s, and probably even earlier. Now I recognize that somebody will send me a nasty email that says “what about in war, wilderness, or austere conditions!!?” So let me save you the trouble and say those are desperation environments, not the conditions in most civilized countries, though I make an exception for the USA, who have yet to figure out an equitable, effective, or sustainable healthcare system. There cannot be malpractice reform until there is doctor behavior and system reform, as doctors in all countries seem completely uninterested in any type of self-directed change.
Whether or not doctors and to some degree all healthcare providers accept patients are customers, I suspect there will never be a change in their mentality. Most providers are told that at some point, but then go on to ridicule that idea and assume some posture of moral superiority by simply as existing as a doctor compared to “mere mortals.”
But this is where lessons from the Fire Service come into play again. Every Police Officer and most firefighters have heard a member of the public say (probably directly to them) “I pay your salary!” especially when they are not getting their way. Guess what? Patients are paying your salary! Whether you work in a private pay system or a government pay system (tax based), you are the employee of the patient. Now while it is not medically advisable to give the patient everything they want, and certainly Michael Jackson proved that beyond any doubt, it is necessary to give the patient value.
Anyone who has spent the day working at a small fire department understands this concept. Tax payers are not reserved in pointing out that “The firemen sit around all day, eating the equivalent of a Thanksgiving feast twice a day, and when not doing lots of nothing watching TV, are paid to play basketball and ping pong.” So in order to stop tax payers from totally defunding these departments, the fire service takes on a 2 pronged approach. The first is public relations. The world over, not too many people hate firemen, maybe the oddball who legitimately had a bad experience here or there, but with active public outreach, it is firefighters who control the narrative to their favor. The second thing fire departments do is demonstrate value. This takes all kinds of forms. During my time as an exchange firefighter in Slovakia, during a January blizzard in Bratislava, the capital in the formidable Tatry Mountains, I went with a crew dispatched to use their saws to cut a tree which had fallen across the road. In the US this would be the responsibility of a multitude of non-emergent public service, but at the time, it was explained to me “part of our job is to maintain readiness and emergency response capability, if we are not capable of driving on the road, we are not performing our duty.” In the USA, I have been on all manner of “non-emergent” calls with various fire departments, both municipal, and even industrial. Never once did somebody call 911 and hear “sorry, call us back when there is a fire.” (“I am not a specialist in that!” is a common utterance of doctors) Unless there was another emergency responder and even sometimes despite there being another emergency responder, the fire department shows up, and does what it can. In fact, it is possible to go an entire career in some fire departments around the world and never once fight a fire. But showing up in the moment of need, even if it is just to provide moral support, makes you a hero to somebody for the rest of your life. I will offer, that person is not likely to sue you. That person can be counted on to support you during budget time and even during times when a preventable mistake was your fault. There was a time in my life doctors were treated similarly. In fact, my family’s primary care provider when I was growing up, was a legend of a doctor. We had his private phone number, if we called him in the middle of the night, even for something as simple as a fever and not being able to sleep, “Doc” as he was known, would meet you at his office in 20 minutes. Even then, in the 1970s and 1980s, “Doc” could be relied upon to fix whatever your problem was, including an antibiotic injection or sutures, right in his office. No he didn’t have his own labs or X-ray, but in fairness, at the time, Piccolo didn’t make point of care testing machines either. But we live in the Information age, technology is so advanced we can do more from the phone in our pockets than the entire US Government computer systems could do in the 1970s and 80s. How is it possible to accept or make the argument for “no equipment?” If you can spend $700 for your new Iphone, your practice can afford point of care testing for basic labs. Not only that, volume usually makes things cheaper. Ask anyone who deals in retail or wholesale.
“Sorry, we are closed…” The fire department is never closed… The Police department is never closed… The Emergency Department is never closed…Even “Doc” was never closed. But somehow “later”, “tomorrow”, “in 2 weeks”, “ in 40 days” is an acceptable answer for a doctor? Who not only commands some of the highest wages in whatever society they live in, but also the highest of social position? Wow… I am not even sure how to explain that to the parent that has to go to work in the morning to put food on the table for their sick kid when they are up all night. I am not sure how to explain to the new mother that while she worries whether or not she is properly taking care of her first child, who she loves more than life, that the doctor is too busy to help her, if only with a reassuring word. After all, work is not “his life”.
Some would say after hours, “if you think you have an emergency, go to the emergency department.” Those “some” are the answering services of primary care providers. They are the nurse on call lines. They are the emergency communication centers. So riddle me this Batman…If the answer at 0 dark 30 is “go to the ED” why is that not the same answer at 0900? Convenience of the doctor? I don’t see the fire department scheduling the next emergency call or fire at their convenience.
I suspect that some doctors would say “not every patient or condition is an emergency,” and I would not dispute that. But there is no way for the patient to know that in the moment of need. I was on a trans-Atlantic flight once, over the middle of the North Atlantic Ocean, the nearest runway that could accommodate our plane was Iceland. When you are an emergency provider, these details are readily apparent to you. A person who spoke a language nobody else on the plane spoke became distressed. The flight attendant came on the speaker and she didn’t ask if there was a fireman on the plane. She didn’t ask whether or not they should call the fire department. She asked for a doctor. It was an emergency to every crewmember of a major commercial airliner. I was passed a little white phone where a doctor in Frankfurt, with a German accent that barely made his words understandable to me said, “I have only one question, do we need to divert the plane?” To which my reply was “I have not even begun to evaluate the patient…” He waited on the line…
Permit me to point out the Gravity of this situation? With a 747 filled to capacity, the airline was ready to pay the cost of an emergency unscheduled landing at a major airport. They would be responsible to house, feed, and since it is the EU, compensate every passenger on the flight. They would then be required to rebook and transport every person on the plane to their destination, from essentially a tiny Island in the Atlantic, at the earliest opportunity, regardless of cost.
They were willing to do this on the word of “a doctor” whom they had never met, who had no credentials upon him. They didn’t ask how long I had been a doctor. They didn’t ask where I worked or what kind of medicine I practiced. (Probably a good thing too or they might have diverted the plane, nobody waits for the explanation, I am also a paramedic for more than a decade, including a few years at one of the busiest and best hospitals in the world, and a fireman) They asked only 1 question. “Do we have to divert the plane?” They never called for a fireman. But I am sure, had they diverted, the minute the plane touched down, there would have been a fireman there.
But the story doesn’t end with a heroic life save with a medical kit better outfitted than 99% of all US ambulances. It ends with a patient who was dehydrated, had a headache, and was hoping for some aspirin. Which he got…
So how much is answering the call for help worth? Depends on who you ask. But to the scared, the uneducated, the person, or the family, even hearing nothing is wrong or it will be ok is worth all the money they can pay. If it wasn’t, they would not have called or came.
So just keep in mind, if you don’t want to be sued, don’t start off with a “fuck you, you worthless plebe, don’t call me unless I think you are worthy.” Don’t play “guess the diagnosis roulette with the most minimum equipment possible”. I once heard a religious person say “To whom much is given, much is expected.” I would add, “especially from the people who pay your salary one way or the other.”
We are all consumers, we all want value for our money and time. So even if a patient doesn’t need a medicine or a surgery, demonstrate the value that you provide to your patient. If you are not providing the value they need. The person who needs to change isn’t them or how they use your system; it’s you!
In the US Navy, all members are required to learn the general order of a sentry. 1. To take charge of this post and all government property in view.
- To walk my post in a military manner, keeping always on the alert, and observing everything that takes place within sight or hearing.
3.To report all violations of orders I am instructed to enforce.
4.To repeat all calls from posts more distant from the guard house than my own.
5.To quit my post only when properly relieved.
6.To receive, obey, and pass on to the sentry who relieves me all orders from the Commanding Officer, Command Duty Officer, Officer of the Deck, and Officers and Petty Officers of the Watch only.
- To talk to no one except in the line of duty.
- To give the alarm in case of fire or disorder.
9.To call the Officer of the Deck in any case not covered by instructions.
10.To salute all officers and colors and standards not cased.
11.To be especially watchful at night and during the time for challenging, to challenge all persons on or near my post, and to allow no one to pass without proper authority.
A fair few of these are required of doctors in most countries, especially number 5. So if you plan to leave the office and your patients in order to have “your life”, then the reality is your relief is the ED. It makes me wonder; if a patient needs to go to the ED at 1601…Why does the patient need to see you first between 0800 and 1600 for the exact same complaint/problem? It’s not for the ED or the system. It’s for you. The middleman taking his cut. Doesn’t the patient you are managing post ED know they are ok until their next already scheduled appointment? If they are not ok, what are you going to do for them the ED cannot? Do you really believe you are saving anyone money by making them stop at you first sometimes? If they didn’t have to stop at you first, couldn’t that money be put towards expanding the ED? The centralized, equipped, 24/7/365 facility.
Being a doctor does not change the fact that he who has the gold makes the rules. The people with the gold pay your salary. They want value. You ignore that at your own peril.
They don’t teach this kind of stuff in medical schools. Many doctors learn their attitudes from the colleagues who are just speculating, if they ever learn it at all. But you can bet they teach it and live it at the fire department. You can bet that I do. I never heard a person call a fire department in another country because they could not get timely help from their local one first. None of my patients called a doctor in another country because they couldn’t get timely help.
Another one of those fire department lessons…”It’s better to have help and not need it, than to need help and not have it.”