Difficult Doctors and Consequences
I’m going to work this morning. As such, I have been wondering who is on call today. Since I work in the emergency department, a lot of my day is spent calling consultants (for the non-medical that means other specialists) either to admit patients or to manage complicated issues like stroke, heart attack or trauma.
A quick glance at the call schedule sometimes gives me a little anxiety. Because certain names can mean almost certain conflict.
I learned about this in medical school and residency. I remember that a few residents or staff above me could make life exceedingly difficult.
As a staff physician, in practice now for 29 years, I still feel this sense of dread.
The conversations are like this, culled from decades of experience: “What do you want me to do?” “It’s not my problem.” “I don’t understand why you keep calling me.” “Did even you examine the patient?” “You better watch your mouth.” “Why don’t you call me back when you’ve finished the workup?”
At one point in my career I worked in a location without a neurosurgeon. One neurosurgeon who took call in our nearby referral center would routinely call back…collect. (For those of you of the smart-phone era, it meant that the receiver of the call had to pay the…oh never mind.)
All of this has consequences. First, it often effectively creates a barrier. The difficult physician sets up this verbal and emotional hedge which others learn not to cross. Or maybe it’s more like the stripes of skunk or rattle of a Diamondback. You learn pretty quickly that it’s often not worth the trouble. But that leads to the second consequence:
Consequence two is that it impedes patient care. Physicians like me are the classic, 'Jack of all trades, master of none.’ I have a case that makes me uncertain, if I’m not quite sure but need the guidance of a specialist, then I might just do my best, look some things up online or in a textbook (you know, ancient scrolls bound and printed on paper…). I might do almost anything to avoid ‘poking the bear.’
This is how bad things happen. But for the difficult physician, it’s no big deal. When negative consequences occur, all they need to say is ‘I was available, why didn’t you call?’
In medicine as in so many professions, personality conflicts are problematic. But sadly, it can be especially dangerous in a field where the right information and the right experience can be life-saving.
(And I’d be remiss if I didn’t say that this is a huge problem for nurses as well, who are far too often subjected to loud rants or profanity when they call physicians.)
I understand that some specialists are very stressed, or very unhappy or wildly burnt out. I get it. But that doesn’t make it any easier for the rest of us who have to interact with them.
Not long ago I called a cardiologist for a patient with an MI (heart attack). He was kind on the phone. He said, ‘I had better come on in…see you in a bit.’ He decided to take the patient to the cardiac cath lab. While things were getting prepared he sat down and chatted with me about medicine and life.
What a delight.
Pity all of our interactions in healthcare can’t be the same. Physicians and nurses would be happier. And ultimately patients would be safer.
Edwin
PS Tell me about similar situations in your own career in the health professions or in other career fields! I’d love to see discussions in the comments.
Som true…I especially like ‘watch your mouth.’ You KNOW that specialists has the ceo of the hospital on speed dial….it’s like Putin threatening to go nuclear. ,the decline in civility and professionalism over the past 4 decades has been astonishing, but NB it correlates closely with the rise of EM as a successful speciality. If you don’t draw limits your colleagues, and their patients, will define your practice for you in ways that are unpalatable, and of course abusive. And by puffing our chests out macho like and insisting we can do anything (scapular nerve blocks , ultrasound, thoracotomies, etc)mit shoudl come as no surprise our colleagues EXPECT us to manage anything off hours, non billable etc. to our misfortune, we came of age just as Medicine was transforming and being corrupted for the worse. We didn’t have time to mature, form professional boundaries, achieve A dedicated NIH institute to support the intellectual foundation of our practice. Defining ourselves by clock , convenience and venue, rather than organ system, or criticality, has proven to have some real problems. We needed to draw the line at WHAT we treated at any hour, and that should have been confined to real emergencies. Ie surgical and medical critical care, resuscitation, and basic triage , not school<physicals, work excuses, etc. and because we didn’t, otters defined our practice and thus our speciality for us. to be sure we always had, and it was ineluctable we would have, our drunks and uninstitutionalized psych patients, but why are we seeing non suicidal depressed patients, in the ED? I won’t belabor Wall Street, the rise of the suits, our own predatory greedy ACEP (the rape of Emergency Medicine) , Covid, inflation, the collapse of primary care etc. they have have been Well catalogued by more capable bards. But Inadvertently we have created some of these problems . How? Our natural emphathy, sense of humor, enthusiasm, confidence and broad training have their dark side- hubris, masochism , cynicism. And We allowed ourselves to be all things to all patients and doctors. There is an inherent and semantic contradiction in ‘emergentologist’ treating cystitis, ingrown toenails, work excuses, etc. We originally were for ‘emergencies’ - minor problems were routinely turned away referred to their primary docs (remember those?) we didn’t have the staff or the inclination to deal with this .but we have been converted , passively and actively, into ‘convenientologists”. Along the way we found that minor urgent care stuff could be quite lucrative at the billing rates we could charge, and even out staffing, work etc. but we made. A huge error intellectually. We were sliding back to being ‘doc in the box’….specialists by definition become more refined in their practice , focus etc. esp as they mature., not expanding the scope of their practice. I’m confident anyone reading this post has at least one surgeon who ONLY does lap cholcystectomies, right? And who is doing just fine, correct? It was one thing to expand ultrasound , even though initially it was not reimbursed and only allowed radiologists to slack off or en stay at home, read and bill in the morning (how is that remotely useful for patient care?)but we started shooting ourselves in the foot when we seem to have in decided it was our responsibility/duty to cure all the ills of our health care system and declining professionalism of our colleagues .l by definition, we already tithe away more free care and make ourselves available the poor and downtrodden at all hours . How is the world did we even think of doing smoking cessation programs, drug addiction treatment, blood pressure med renewal, counseling etc in the “EMERGENCY ‘ department (or even Room)?rEven Dr green in TV wasn’t that self destructive . As a consequence we lost control of scope of our practice and thus our practice. You can’t blame suits or specialists entirely when they witness such feckless masochism . They are under pressures too. That same abusive cardiologist is coming to work every day expecting to get paid 5% less and see 5% more patients. One wag said sagely the only problem with EM is WE don’t have an emergency room to abuse. Even ‘observation’ medicine is problematic as we have learned to our detriment. Initially a good faith effort to provide tests, care continuity, etc, it has been exploited to allow hospital to downsized staffed beds. It would not be so bad if we were still able, as we were back in the day, to unilaterally ‘close’ the department when overwhelmed, (yes grasshopper,that was the exclusive prerogative of the Emergency department medical director back in the day; he /she had crate Blanche to determine what was unsafe, and why not? Who else had better training more accountability to all the constituencies”…..but those days are long gone but we are where we are now. The cat is out of the bag, and as the suits and Wall Street crush us, we are inevitably sliding into the worst aspects of critical care (stress, intensity), primary care (our doors a]our open to see you urin24-7) Psychiatry (holding patients for days who belong at state mental hospitals) we have not just become indispensable (which too many in our specialty blithely Embraced without any mature consideration of the consequences) and then Covid was the coup de Grace. And now we have the routine absurdity of our understaffed nurses handling 4 patents on vents while the ICU refuses to accept another patient because THEIR nurses are already at their max allowed two patients per RN. The only solace supposed is this nonsense is catching up with our abusive burnt out colleagues in other specialities. , however, feces runs down hill, and the suits will never squeeze them to be actually “on call”. So it is getting worse out their for every doc, but at least They can say to themselves ,like Bogie to Bergman, “we will always have the ED” to off load to ,ignore, act out on, abuse….we have become a monster and we are not entirely blameless. The only out is unionize, and fast, and let the chips fall where they may. But it’s probably already too late….unlike pilots, air traffic controllers etc, we have let physician extenders slide into our profession and while we will always need at least one board certified EM physician on duty so the ambulance chasers have someone to sue, we have a lot of downsizing to do before we get to that steady state. We are already grossly over expanded in residency positions due to our own greed wanting to staff community hospitals with cheap trainees for our practices…another ‘own goal’ by the way I should point out.
Great post! Could not help asking about your line "As a staff physician, in practice now for 29 years"...are you a PGY-29 or some other number? I graduated med school in 2001 so after July 1 my PGY always equals the current year, e.g. currently finishing up my PGY-22 year.
I often wish our badges or medical staff profile reflected our experience maybe a star on the back stacked up like football helmets recording sacks, lol. Of course, years in practice does not definitively equals skill but it definitely correlates.
“Life is short, and art is long.”