The Fire Surgeon

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That is the coolest title I have ever heard…Not one I have ever been called myself, but I was introduced to it by somebody who was. A firefighter and later Emergency Doctor who worked as both a firefighter and doctor for a fire department.

Talk about a dream job…A firefighter and a doctor, if that doesn’t just bleed altruism, I don’t know what does…

There is a popular saying among firefighters, “it’s not something you do…It’s something you are…”

This was popularly described in the movie Backdraft, where one of the characters said to the protagonist, “the funny thing about firemen…night and day, they are always firemen…”

I started my career in the fire department, and fireman is a title I have had. For some time. But more than just a title or a job, it is a way of thinking, a way of living. Few things are more altruistic than answering somebody’s call for help, showing up and doing your best. Which sometimes works out and sometimes doesn’t.

After responding to a fatality call early in my fire career, I promised I would be better than that day. More knowledgeable, more skillful, I would not be caught incapable again… That led to a pattern of behavior, which eventually became a habit. Studying, reading, learning, practicing, trying. The goal everyday was to be better than yesterday. It became a life-long pursuit, it is never enough for me to know or do the minimum. The unyielding goal is perfection. It is not realistically achievable, and believe me, I have my share of failures, and I take them personally. My self-criticism is far in excess of  anything external.

I have been to the temple of St. John, to the traditional home of the Knights Hospitaler, the very birthplace of the Maltese Cross, and origin of all firemen.

But this attitude and devotion to excellence, to a way of life which focuses on having the greatest position in the world, the person who gets called when things go wrong for other people. I still think that is a great honor, something that has to be earned everyday. However, it often doesn’t endear me to other doctors.

I know, call my friends, and have been mentored by some great doctors on the road to becoming one. Some are emergency physicians (a great many), some are anesthesiologists,  and some are (and were) surgeons. But I have noticed that not all doctors are as great as they are. Many of them do not want to be. This creates a lot of conflict for me. I see them as not living up to the expectation, and it makes me angry. Especially when I constantly hear from them “I don’t want to learn anything new or more” or “what’s in it for me?” Learning new and more things is part of being a doctor, it is expected by everyone from licensing agencies to patients. Not learning more is essentially dereliction of duty for doctors, it is fraudulent. “What’s in it for me” severely conflicts with the altruism intrinsic to firefighters. Negligence, laziness, and greed just don’t sit well with me. It never will. It is what it is.

Many doctors I have met, all over the world, are multi generational doctors. Grandparents, parents, etc. were all doctors, so they naturally became one too. They have an amazing sense of entitlement. But they are not alone. If I had a dollar for every person I have met who thinks they are entitled to all sorts of things simply for graduating medical school, becoming a specialist, or achieving a title, I could feed, cloth, and provide medicine to the whole world. It frustrates me.

Today, I was going through my usual routine of checking out my daily dose of expanding medical knowledge, when I ran across an article, linking to a study that described how US surgeons were improperly prescribing opioid medications, and 2 things in the article caught my attention. The first was they claimed there were no surgery specific guidelines for treating pain. This to me is absolutely a merit-less excuse for not knowing how to do ones job. There are many guidelines that describe the treatment of both acute and chronic pain in patients, and surgeons not being able to do it is negligence. The other thing I was struck by is that they were essentially trying to justify insane behaviors like prescribing opioids for 6 plus months at a time and claiming they don’t have the training to recognize, prevent, or deal with addicts. I know every doctor who ever graduated medical school was given instruction and education on treating pain. It is intrinsic to medical education. Now this may have been poorly done, I will accept that as an excuse, but to claim ignorance is disingenuous.

One of the things I have noticed about all forms of specialty training and specialist physicians, is that it doesn’t expand their skills and knowledge. It limits it. Rather than learn about all medicine as it applies to what they will encounter, specialty training purposefully narrows knowledge and capability, and often ends with “that’s not my job.”

There is merit to recognizing ones limitations. There should be no shame for calling for help. But rather than using this in the way it was intended, most specialists I encounter use it at best as a crouch for inability, and at worst an excuse to not make any effort to better oneself. You can see where this conflicts with the very core of my beliefs…

One of the things about firemen is that they are expected to be capable at all aspects of their job. Preventing fires and accidents, pre-planning  for them, mitigating everything from medical emergencies to major disasters and everything in between (like fighting fire), cleaning up after them (salvage and overhaul are the industry terms), and even investigating the causes and laws when there is a fire. It is a soup to nuts requirement. While very few are great at all of it, and teamwork is essential, everyone is expected to have a minimum capability to do their job. They purposefully train regularly on skills to keep ones they don’t use often fresh. Doctors don’t do that at all. Not in any meaningful way. But to me it seems logical. A doctor should be capable of preventing disease, capable of performing the actual interventions, both surgical, and medical that they use, and caring for the patient after these interventions. Perhaps for the rest of the patient’s life.

Not being able to do all of this and requiring a myriad of other doctors for even the most minor or intrinsic aspects of the job, like providing pain control post surgery, should be embarrassing to everyone who cannot do it. Every time they call for help they need to see it as a failure of their ability. They should resolve and rectify these inadequacies. When things go wrong, while “no-fault” education or remediation is a great thing, there is no such thing as “no-responsibility”. While there may be no fault, there is certainly failure, and certainly responsibility.

Another thing doctors like to do is claim that failures are everyone’s doing but their own. “The lawyers”, “the lawsuits”, “patient satisfaction”, “where I work”, “we’ve always done it that way”, I could list every pathetic excuse they use. That’s exactly what they are too, pathetic excuses. Distraction, deflection, denial of responsibility.

That is why I am against malpractice reform in all countries. The only thing keeping the medical profession from utter laziness and inadequacy is the legal profession. In fact tort laws need to be expanded to make sure doctors are accountable.

When I bring this kind of stuff up, a common thing I hear is “that is unprofessional to say such things.” But it is not unprofessional, it is simply not what doctors want to hear. They want to be told how great they are, how special they are, and how much respect they deserve…Bullshit. What is professional is recognizing ones shortcomings, admitting mistakes, apologizing when necessary, constantly trying to improve both the system and ones-self, taking responsibility, doing what is right even when it doesn’t directly benefit them.

Excellence is not a goal. It is a behavior.

If everyone in healthcare and medicine wants to be told how great they are, they need to start earning it. In order to be great they have to be more than the minimum to not get fired or sued. They need to be capable of everything that is required of them, even if it is new, outside their comfort zone and self imposed limitations. Otherwise, the titles and pleasantries are not respect, they are hollow and worthless. A mockery of respect.

One of my former bosses once asked me, if being a firefighter is so great why did I stop? To which I replied “I didn’t, but supposedly becoming a doctor was a promotion.”

It doesn’t seem like a promotion, and the longer I am in medicine, the less impressed I am. I see a majority of doctors as arrogant without merit. Respected without deserving. Demanding without earning.

On 15 April 2017, I am not convinced doctors should be paid anywhere near what they make, and should not be respected anywhere near what they are. The few good ones tolerate the majority of mediocrity and laziness. So they are included and judged by the company they keep.

Inaction is acceptance. It is making me sick and it is in my face every day.