Great comment, as usual. A few thoughts, especially related to this column. We don’t save lives; we postpone death. I have often described emergency physicians as conductors on the train of life, which is a one way journey. Our job is to try to prevent fellow passengers from getting off prematurely. We do not, in many ways, do a service to our patients if in improving the quantity of life we markedly diminish the quality. I see many of the wonderful, yet phenomenally expensive new medications (often heavily advertised on television) touting a “significant improvement” over current regimens. Significant, yes, but almost always statistically significant (sometimes as little as two months longer survival, on average) rather than clinically significant, disease oriented rather than patient oriented. A new anti-hypertensive medication may lower the average systolic pressure by 4 mm over a large population, but if it doesn’t reduce the incidence of heart disease, kidney disease, or strokes, so what. Statistically significant but not clinically, seems to be what is in the ads and clinical papers. Preventive medicine is where it should be. The most dangerous substances in our society - tobacco, opiates and stimulants, alcohol, too much salt and sugar, and dangerous behaviors (not wearing seat belts, driving too fast and/or while impaired (and too many overly tired physicians in training), ignoring preventive immunizations, etc. The loss of productive years from premature deaths due to Covid and drug overdoses is terribly sad, and a huge loss for our society. We are fragile; I love the term, and knife edge of homeostasis. Thanks for educating us.
Edwin, I’m PGY 41 and still at it and love EM but, like you, I hate what non medical administrators have done to it. You have a tremendous gift to express all of our frustrations.
Well written, as usual. This strange landscape is why so many of us old timers have bailed. My perspective: the way things are going, I most likely will not live into my 90's, nor do I want to if it means being dependent on multiple medications, procedures, and spending time at endless appointments that will drain our life savings. So hubby and I decided we were both done and plan to enjoy life now.
Then again, life throws unexpected monkey wrenches into the lives of those around us. Our niece's husband, who never smoked, has small cell carcinoma of the lung...and since February it has mercilessly invaded his bones, spine, and brain, regardless of the "new" treatments that have been tried. He is 45. I will be very surprised if he is still alive by Thanksgiving.
Another friend's husband was trimming tree branches for a neighbor and fell, breaking his neck. 70 and formerly healthy. Now paralyzed from the neck down, likely ventilator dependent long term.
I sure don't have the answers. But our healthcare system's long free fall started when the bean counters took over. "Public satisfaction" is a poor measure and a no win situation for all. Folks want miracles that we can't provide.
As always, you describe the current chaos in our medical system so clearly non-medical people can understand the forces destroying our healthcare system. As Dr. Lindemann and I said 30 years ago in Modern Medicine: What You're Dying to Know, the U.S. healthcare system is great for emergencies, but good primary care was disappearing even back then. I really don't see any remedy except physicians beginning to practice independently with Direct Primary Care. In time, I think, there will be parallel healthcare systems, even including a growing respect for alternative care. We need to stop dissing those who think outside the box. The medical profession is dangerously close to making Semmelweis' out any physician who sees details others miss.
The vast majority of my patients (ER) fall into one of two categories: physically fragile (as you describe here) and mentally/emotionally fragile. The second group are the ever increasing number of worried well who, while physically healthy, appear unable to deal with aspects of life which previous generations would not have given a second thought too. This encompasses the anxiety and panic attacks, but extends to the teenagers who present with chest pain petrified they're having heart attacks, the twenty-one year old presenting because she thinks she's having a stroke (12th visit for it this year alone), the myriad of patients coming in with common colds just to make sure it isn't something bad, the healthy 30 year old coming in because she fell and banged her elbow and when informed that she did not break any bones counters that if that were true how it can possibly still hurt. These patients are almost more exhausting than the physically fragile. But the combination of the two is enough to make this 10 year veteran of the ER desperately cast about for an exit strategy.
I like the way you tied the three issues of CPOM (the corporate practice of medicine) with our increasing load of octogenarians, nonagenerians, and centenarians and the complexity of new meds and imaging modalities.
They really do potentiate the difficulty of our jobs. 2 + 2 + 2 = 8.
But the most onerous for the new generation of docs must be the greedy CEOs whose only motive is profit. We docs have become just another commodity to them, just another contractor like an electrician or plumber.
Great comment, as usual. A few thoughts, especially related to this column. We don’t save lives; we postpone death. I have often described emergency physicians as conductors on the train of life, which is a one way journey. Our job is to try to prevent fellow passengers from getting off prematurely. We do not, in many ways, do a service to our patients if in improving the quantity of life we markedly diminish the quality. I see many of the wonderful, yet phenomenally expensive new medications (often heavily advertised on television) touting a “significant improvement” over current regimens. Significant, yes, but almost always statistically significant (sometimes as little as two months longer survival, on average) rather than clinically significant, disease oriented rather than patient oriented. A new anti-hypertensive medication may lower the average systolic pressure by 4 mm over a large population, but if it doesn’t reduce the incidence of heart disease, kidney disease, or strokes, so what. Statistically significant but not clinically, seems to be what is in the ads and clinical papers. Preventive medicine is where it should be. The most dangerous substances in our society - tobacco, opiates and stimulants, alcohol, too much salt and sugar, and dangerous behaviors (not wearing seat belts, driving too fast and/or while impaired (and too many overly tired physicians in training), ignoring preventive immunizations, etc. The loss of productive years from premature deaths due to Covid and drug overdoses is terribly sad, and a huge loss for our society. We are fragile; I love the term, and knife edge of homeostasis. Thanks for educating us.
Edwin, I’m PGY 41 and still at it and love EM but, like you, I hate what non medical administrators have done to it. You have a tremendous gift to express all of our frustrations.
God bless you and all of us on the frontlines.
Dr Jim
Well written, as usual. This strange landscape is why so many of us old timers have bailed. My perspective: the way things are going, I most likely will not live into my 90's, nor do I want to if it means being dependent on multiple medications, procedures, and spending time at endless appointments that will drain our life savings. So hubby and I decided we were both done and plan to enjoy life now.
Then again, life throws unexpected monkey wrenches into the lives of those around us. Our niece's husband, who never smoked, has small cell carcinoma of the lung...and since February it has mercilessly invaded his bones, spine, and brain, regardless of the "new" treatments that have been tried. He is 45. I will be very surprised if he is still alive by Thanksgiving.
Another friend's husband was trimming tree branches for a neighbor and fell, breaking his neck. 70 and formerly healthy. Now paralyzed from the neck down, likely ventilator dependent long term.
I sure don't have the answers. But our healthcare system's long free fall started when the bean counters took over. "Public satisfaction" is a poor measure and a no win situation for all. Folks want miracles that we can't provide.
Another great one cousin. You have a true gift of expression that is beyond good. Please keep it up.
As always, you describe the current chaos in our medical system so clearly non-medical people can understand the forces destroying our healthcare system. As Dr. Lindemann and I said 30 years ago in Modern Medicine: What You're Dying to Know, the U.S. healthcare system is great for emergencies, but good primary care was disappearing even back then. I really don't see any remedy except physicians beginning to practice independently with Direct Primary Care. In time, I think, there will be parallel healthcare systems, even including a growing respect for alternative care. We need to stop dissing those who think outside the box. The medical profession is dangerously close to making Semmelweis' out any physician who sees details others miss.
Thank you for this thoughtful look at how the Medicine has become a victim of its own success.
You accurately describe how the corporate Triumph of the Bureaucrats is driving young physicians out of the field.
The vast majority of my patients (ER) fall into one of two categories: physically fragile (as you describe here) and mentally/emotionally fragile. The second group are the ever increasing number of worried well who, while physically healthy, appear unable to deal with aspects of life which previous generations would not have given a second thought too. This encompasses the anxiety and panic attacks, but extends to the teenagers who present with chest pain petrified they're having heart attacks, the twenty-one year old presenting because she thinks she's having a stroke (12th visit for it this year alone), the myriad of patients coming in with common colds just to make sure it isn't something bad, the healthy 30 year old coming in because she fell and banged her elbow and when informed that she did not break any bones counters that if that were true how it can possibly still hurt. These patients are almost more exhausting than the physically fragile. But the combination of the two is enough to make this 10 year veteran of the ER desperately cast about for an exit strategy.
I like the way you tied the three issues of CPOM (the corporate practice of medicine) with our increasing load of octogenarians, nonagenerians, and centenarians and the complexity of new meds and imaging modalities.
They really do potentiate the difficulty of our jobs. 2 + 2 + 2 = 8.
But the most onerous for the new generation of docs must be the greedy CEOs whose only motive is profit. We docs have become just another commodity to them, just another contractor like an electrician or plumber.
TED SWITZER, MD, FACEP
Great review👍
Well said.