There are a lot of things happening in the current healthcare environment that make medicine a tough field for anyone. It truly is no wonder that physician burnout is occurring in epidemic proportions and that suicide rates are skyrocketing as well. We are frustrated. We are overworked. And we have less and less people that value our opinion–the one we spent all of our twenties and all of our money trying to hone.
Not the least of which includes are actual patients. Those people for whom we are sacrificing time with our own family in order to provide their care. It seems the public trusts Dr. Google and the words of strangers over modern medicine more and more all the time. Yes, gone are the days of paternalistic medicine. But, has that gone too far? Are patients (and even more so, family members) OVERLY empowered in advocating for care (or the refusal of such)? Time and time again this is actually detrimental to the patient. I will admit that there are times when the patient definitely benefits. However, I personally think advocating for yourself to the insurers is better time spent than arguing with your physician (who likely has their hands tied by administrators and insurers anyhow).
This isn’t just my spouting off my own frustrations. One of the only prospective (well-designed) studies about patient satisfaction showed that higher patient satisfaction scores were directly related to higher hospital admission rates, higher pharmaceutical costs, and increased mortality. Sure, if you do a Google search about patient satisfaction and outcomes, you’ll find plenty of studies that correlate patient experience more directly with patient outcomes–they all claim that patients know how to direct their care. BUT, what about provider satisfaction? Physician satisfaction? Nurse satisfaction? Therapist satisfaction? If those actually providing your care are fed up and miserable with the hospitals, insurers, their groups, their pay structures, their hours, how do you expect them to provide the absolute best, highest quality care? Therefore, I’d like to see the study that compares patient and provider satisfaction scores–and then extrapolate those results to patient outcomes. (If you’re interested in this, please feel free to contact me. I think there would be some interesting findings.)
Ok, so obviously these thoughts don’t come out of thin air. And those of you that are in healthcare field that so generously take the time to read my blog (even if I didn’t post for a whole month), know that we all have a laundry list of anecdotal stories about this. So here goes:
The Mama Bear/trauma surgeon combo is usually a good thing…until Mama Bear suspects danger for someone else’s young. When a teenager rolls a car, slides 400 feet, and is then found another 50 feet or more from the car… that teenager needs to be evaluated at the nearest trauma center–NO MATTER WHAT. Every trauma/EMS policy in the country would agree to this. Do they necessarily meet criteria for a full trauma team activation? No. But, they at least need to evaluated in a formal, acute setting. There are a number of injuries that could have occurred–life threatening ones like a head bleed, a collapsed lung, a blood filled chest, blood around the heart, a shattered liver/spleen/other internal bleeding, etc. The list goes on. When someone’s vital signs say that these things may be a legitimate possibility, that need for a certified trauma center is even more apparent. Yet, people argue! Mothers argue. Fathers argue. Sisters argue. Brothers argue. They argue with the EMS chief, they argue with the trauma nurse that so kindly put them in a family waiting room while waiting on results, and then they proceed to argue with the trauma surgeon that is actively ensuring that their family member isn’t going to die anytime soon. Their son that may or may not be intoxicated/under the influence. Their daughter that may or may not have been at fault in the accident. Their son that may or may not have skipped school. Their daughter that may or may not have fallen asleep at the wheel. Who cares about all those details? The details that truly matter are the patient’s mental status, their blood pressure, their heart rate, their breathing rate, their oxygen saturation, their lung sounds, their heart sounds, the presence or absence of pain. These things need to be evaluated and scans/operations need to ensue within the hour. The golden hour. They do not need to be evaluated by their “doctor” family members with poor quality X-rays and no ability to correctly intervene. They especially do not need to be evaluated by anyone other than an emergency physician or a surgeon/trauma surgeon. Not a family medicine physician, not an OB/GYN, not a pediatrician, not a psychiatrist, not a dentist, not a chiropractor, not a pharmacist. Sorry to all my primary care friends, but this is not your area of expertise. Sure, if they are in a car wreck and have some vague muscular neck pain 2 weeks later, then by all means, please proceed to your primary care physician’s office–avoid the ER. In the acute setting, with ANY question, the ONLY people qualified to assess my loved one is an emergency physician, and I prefer a surgeon that had a lot of trauma training to evaluate them at some point if there are indeed any injuries. Injuries like a partially collapsed lung and a pulmonary laceration (a cut through the actual lung tissue that could lead to an ongoing leak of air in the chest causing further collapse of the lung)–that needs to be observed in the hospital. There should be no ability for a loved one to try to thwart that process–to try to prevent the patient being transported to the hospital at all, to try to prevent an adequate, efficient (I.e. super fast) workup, and admission–especially if its the care of someone that is legally a minor. They shouldn’t be allowed to sign their child out AMA if it’s not in the child’s best interest. And we, as physicians, shouldn’t have to spend time documenting our heated conversations and our threats to call CPS or making phone calls to risk management offices and attorneys to make sure their child receives the proper care. I should never have to consider getting a judge to give me emergency custody to take care of a teenager. This is just additional stress for healthcare providers and a guaranteed low satisfaction score from the family member filling out the survey that will follow. But guess what, that patient is alive. And there’s a damn good chance that they wouldn’t have been otherwise–or would have required much more intervention.
Alcohol withdrawal is a real thing, people. A very real thing. The kind of thing that freaking kills you. Sure, if you stop shooting heroin, you will feel like you’re going to die, but you will not actually die from the withdrawals. But alcohol is different. Xanax/ativan/librium/benzodiazepines–they are different. The actual withdrawal from these substances can be lethal. Someone who drinks daily will start showing symptoms of withdrawal within 48-72 hours after their last drink. This usually starts with shaking/tremors and altered mental status (delirium tremens) and can proceed to seizures and coma. There are lot of people that drink on the daily that will never experience alcohol withdrawal. Their daily intake isn’t such a significant amount to cause such issues. However, for people that drink entire bottles of wine, fifths of vodka, 12 packs of beer, etc in a one day–they will start to show signs of withdrawal when their serum alcohol levels haven’t even normalized. Most people that have experienced alcohol withdrawal in the past can easily tell you so. If they’ve been to rehab for benzodiazepine overdoses or alcoholism, and they’ve been told they shouldn’t take tylenol because the alcohol has already started to affect their liver function, these patients will definitely go into alcohol withdrawal while in the hospital for any significant amount of time. So, if an alcoholic falls off a ladder, breaks a leg, and needs surgery–they will almost definitely start developing symptoms the day after surgery. To avoid this, we give low dose benzodiazepines or long-acting benzodiazepines to mitigate the symptoms and prevent seizures. For more information, read about the CIWA-Ar Protocol here. There are some people that simply do not respond to this protocol; however, that could be due to the fact that large amounts of pharmaceutical medications these patients need can be intimidating to nurses and physicians alike. Most people with a significant drinking history will be started on a CIWA-Ar Protocol upon admission. The worst thing that can happen to these patients is to be taken off alcohol/benzodiazepines “cold turkey”. A slow, controlled, monitored wean is necessary. When a family member presents themselves as a healthcare provider and then says that it’s the Ativan making their family member crazy and denies any history of alcohol withdrawal (yet, admitted they had been in rehab and they were they ones that told you no tylenol)… they are literally walking a fine line with death for their loved one. It should not be allowed.
Patients and family members should not feel so empowered that they can put themselves or loved ones in harm’s way while still in the hospital. Perhaps if we weren’t all spending the extra time to explain ourselves (because Dr. Google said otherwise), or explain our treatment plan (because that’s not what their friend did), then we could spend more time getting to know people, more time creating a healthy relationship with patients and families rather than continuing an awkward, tense, distrustful relationship that leads to bad outcomes for everyone (the patient, the family, the nurses, and yes, even, physician suicide).
I want people to feel empowered. I want women to feel empowered. I want women physicians to feel empowered. But I do not want anyone to feel so empowered that they can hurt others with their lack of knowledge.
What’s your anecdotal story? Tell me more! I know I’m not alone.