This essay crossed my desk today, and I thought I'd share it - not meant as a critique of anyone's point of view, but I like the way he describes the specialty, journeying all the way to the depths of calling it slavery, yet finds something positive at the end.
'Written by an ER doc, Edwin Leap:
One morning last summer I went to a local ophthalmology office to have an assessment for refractive surgery. I was the only patient in what would be considered a palatial facility by emergency department standards. The nurses and receptionists were all smiles. The floor was clean as a whistle. The marble counter tops sparkled. I filled out my tome of waivers and waited to be seen. I was escorted to the exam room by a very pleasant nurse who did tonometry, mapped my cornea and performed numerous exams that I probably wouldn't have understood if I'd read a book on them. I was then seen by a very friendly ophthalmologist with whom I had a great chat. I was pronounced a superior candidate, escorted back to the waiting room to speak to a scheduler, then given a can of soda and allowed to watch "Dances with Wolves" on the big screen TV in the waiting room (being too dilated to read). When my wife came to pick me up, I didn't want to leave. Wow. What a wonderful experience. But it was wonderful for more reasons than the courtesy that I received. It was a learning experience because it was a study in contrast to my own career.
My learning experience didn't have to do with improving my own customer service, or the cleanliness of my facility, or the smiles on our nurses' faces. It wasn't (although it crossed my mind) a learning experience about how my life might have been if I'd chosen a different specialty. It was, however, a profound insight into what a unique job emergency medicine is, and about how proud we should all be. I could have come away angry, given the cost of refractive surgery. But I wasn't. I could have been envious of the quiet environment and the nice furniture and sculpture. But my patients would just use sculpture to hold empty potato chip bags and cigarette packs. I did, however, come away disappointed in the way we treat our specialty and ourselves, for we are our own worst detractors and critics. There are countless reasons that we emergency physicians should be impressed with ourselves. But mostly, they have to do with the things that conspire to make our practice of medicine difficult, and which we somehow manage to overcome each day.
First, we practice in a specialty unlike any other, for we are self-proclaimed experts in an indefinable field of knowledge. Day in and day out, night after night we make snap decisions in two hours that would give most physicians hypertension and heartburn. We collate the half-truths presented as history with physical data that makes medical school look like fiction, then try to establish diagnoses in patients who often have problems that are far more social, psychiatric or purely imagined than physical. We deal with complaints that aren't found in any textbook, or we face medical nightmares so complex that all we can do is establish the ABC's and punt. We are a creative group of cowgirls and cowboys. We also practice in an environment that is as close to a legal minefield as the metaphor will allow. In spite of our requirement to see patients for free, we always run the risk of multi-million dollar lawsuits as thanks for providing that free care. And even as lawsuits loom all around, we are counseled to cut costs by ordering less, admitting less and taking more risk.
Furthermore, as if the contingency suits weren't bad enough, we have to face the growing specter of federal accusations of fraud for honest errors in a hopelessly complex system of billing codes. Likewise, we are the victims of social engineering. Since the government can't actually provide free care to everyone (nothing actually being free anyway), they creatively found a way to make us do it via EMTALA. This must surely be one of the biggest unfunded mandates in history, in which we fundamentally work as slaves to the federal government. (To be compelled to work without compensation being the very essence of slavery). And it isn't just the government. Our comrades in the specialty are continually coming up with more ways that we should be the instruments of social intervention, whether it is via mandatory reporting of domestic violence, counseling our patients about substance abuse, or immunizing in the E.D. There simply aren't enough hours in a shift to do all this for the people who might conceivably benefit from it. Thus, we come to expect too much of our limited time and then are led to feel guilty about it.
And in the midst of the madness, we are constantly reminded to be aware of the "customer service" aspect of our specialty. However well the customer service model might work in the general marketplace, it fails when the service must be provided for free. Imagine how long any industry or small business would remain solvent if it were compelled to give its services or products with only the possibility of payment. What if a department store were forced to give everyone clothes (everyone needs clothes, right?), and were not allowed to ask for payment on the spot? What if a barber could bill for haircuts, but not ask for compensation at the time the service was provided? No other industry that I can think of is forced to work under such conditions.
Finally, we don't practice a specialty that promotes long life and well being. We work odd, varying hours which disturb our sleep cycles. Not only are we awake in the wee hours of the night, we are awake and stressed. We eat poorly, drink too much caffeine and do too few things to promote our personal happiness. Furthermore, we are constantly exposed to the risk of communicable diseases or violence in our workplace. And every minute of every shift, anything imaginable can come through the door, whether on an ambulance stretcher or in the arms of a distraught parent. It may be an apneic child, it may be an exsanguinating gang member, it's all ours to sort through and try to save. When we fail, we have the equally horrific task of telling family members, then watching as they scream and slump to the floor. As an unforgettable illustration, one terrible night this past summer, my partner and I cared for another of our partners who sustained a lethal head injury in an MVA on the way home from a shift. Could we close the doors, hang a wreath and mourn? Of course not, for the patients kept on coming. What can I say? Surreal doesn't begin to describe our job.
So I'm weary of criticism. I think we are amazing. I think we do incredible things in conditions that most practitioners would find simply unbearable. We work hard, we work fast, we try to be nice when we are being cursed, we endure the disdain of other specialties who consider us incompetent (except after 5pm), and through it all, we manage to actually care for the people who come to us. They aren't always nice and they don't always pay us, but most of the time they need us and sometimes they actually appreciate us. You see, we are the white knights of medicine.
That may sound a bit melodramatic, but we are the members of the medical community who always do the right thing no matter what. We do it because we were trained to, because we consider it honorable and because the law requires it. We are in battle day and night. We always get to do the things no one else wants to do, to the people no one else wants to care for, like lumbar punctures on AIDS patients, sexual assault exams, "pre-jail screenings" of drunk felons and psychiatric commitments after hours. This is our world, these are our people. And someone has to do it.
In the end, I love what I do. My schedule is reasonable. I have time off with my wife and children. I make a good living. I meet lots of people, some nice, some not so much. Some normal, some bizarre. I usually know what's going to be in the newspaper before it comes out. Sometimes I bond with sociopaths; sometimes I act like one myself. I perform interesting procedures and make fascinating diagnoses. I am constantly entertained by waves of mind-numbing human stupidity. I talk to the dying and I talk to their families. And even though it may not always be fair, no one gets turned away for lack of money, so I get to view the world of medicine from the moral high ground.
I ultimately had my refractive surgery in the beautiful office with the nice marble and smiling nurses. And I didn't complain. Everyone chooses his or her own path. I'm proud I chose mine. And I encourage all my sisters and brothers in the specialty to be proud, because we provide an invaluable service to society. We mustn't let anyone tell us otherwise. As a specialty, we should try a little harder to praise our fellow troops and take pride in our role. And we should learn more often to ignore the volumes of negative studies and articles that seem to tell us, month after month, how poorly we serve the public. But most of all, we should never let ourselves believe that what we do, and the way we do it, is anything less than heroic.'
