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.
My emergency doctor friend James and I talk about all of the horrible consultants we had in the past. “Hey do you remember Cheeawai? What about Molina or Moll?” These experiences stick to you like old gum on a shoe. Now, as with most things, I am on autopilot. I am kind but firm. I pretend like they are so intelligent and funny… “Thank you SO much (for bestowing your wisdom on me! )She is in room 6.”
Oh how familiar this sounds! It never changed in the 40 years I was employed as a nurse. Some stories I won’t retell because I don’t want to terrify nonmedical folks reading this; they hear enough about what is wrong with our system. But your comment about the cardiologist who was so kind and actually chatted when he came in is refreshing. In a time when everyone is harried, hurried, and stressed, to hear that someone out there actually will sit down and take the time to talk honestly and cordially is reassuring that there are still docs who actually care.
I have never understood completely why some specialists are such JERKS and others practically walk on water. I believe it comes down to why they entered the field to begin with and never losing sight of that purpose. No matter what the educational level or how much technology is involved, when it comes to dealing with healthcare and people it is difficult to exclude the “human” factor.
Thankful we have folks like you out there who keep trying.
Yes! These interactions with on-call physicians are perhaps the most demeaning, ego-killing, deflating, maddening interactions we face. I've had F-bombs thrown at me.
On a little different subject, I remember a child who I suspected had aspirated a peanut, The child was stable, and doing well on oxygen. I sent him by ambulance to the university, where a Pediatric Pulminologist scoped him and removed a peanut. I heard later that I was criticized by him for not intubating the patient before transfer...so I was the "crummy doctor from Our Lady of Little Hope"....
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.”
My emergency doctor friend James and I talk about all of the horrible consultants we had in the past. “Hey do you remember Cheeawai? What about Molina or Moll?” These experiences stick to you like old gum on a shoe. Now, as with most things, I am on autopilot. I am kind but firm. I pretend like they are so intelligent and funny… “Thank you SO much (for bestowing your wisdom on me! )She is in room 6.”
Oh how familiar this sounds! It never changed in the 40 years I was employed as a nurse. Some stories I won’t retell because I don’t want to terrify nonmedical folks reading this; they hear enough about what is wrong with our system. But your comment about the cardiologist who was so kind and actually chatted when he came in is refreshing. In a time when everyone is harried, hurried, and stressed, to hear that someone out there actually will sit down and take the time to talk honestly and cordially is reassuring that there are still docs who actually care.
I have never understood completely why some specialists are such JERKS and others practically walk on water. I believe it comes down to why they entered the field to begin with and never losing sight of that purpose. No matter what the educational level or how much technology is involved, when it comes to dealing with healthcare and people it is difficult to exclude the “human” factor.
Thankful we have folks like you out there who keep trying.
Yes! These interactions with on-call physicians are perhaps the most demeaning, ego-killing, deflating, maddening interactions we face. I've had F-bombs thrown at me.
On a little different subject, I remember a child who I suspected had aspirated a peanut, The child was stable, and doing well on oxygen. I sent him by ambulance to the university, where a Pediatric Pulminologist scoped him and removed a peanut. I heard later that I was criticized by him for not intubating the patient before transfer...so I was the "crummy doctor from Our Lady of Little Hope"....