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Touching a (Very) Raw Nerve

How my last article can hopefully teach us all something.

Boy, does social media empower us to say some really nasty things…not that this most recent presidential election hasn’t already demonstrated that.

My recent article, “If You’re Going to the ER, Be Prepared to Yell,” didn’t just touch a raw nerve, it poked it.  But from the massive number of comments and tweets, perhaps there are some things that we can all learn.  I know that I have.

For me, it points out that I must do a better job when trying to make a point, whether in writing, talking, (tweeting), or whatever.  My piece sounded too strongly as if I advocate yelling or aggressiveness as a standard patient/family tactic to drive patient care.  I do not .  It may indeed be a last resort for those who truly believe that the care being delivered endangers them or a loved one, in which case, I completely understand it (and have been the target as well).  If you believe that patient/family yelling is never justified, despite the real or perceived risk to a patient, then we will just agree to disagree.

That said, for my poor wording, which failed to make my real point, I truly apologize.

My point was that patients (and their loved ones) must be prepared to advocate for their own health, even (at times) aggressively .  It is interesting that several non-clinicians with whom I have since spoken shared similar patient care experiences.  Some had yelled (and uniformly agreed that “the squeaky wheel did indeed get the grease”); others wished they had been more aggressive, as they felt the outcome for their loved one might have been better.  And I’ve been the target of patient verbal hostility when a family member perceived that our surgical team was not providing “the best care.”  And sometimes the families were right .  Regardless, my team and I always apologized, as we are representatives of the hospital, after which we tried to determine what actions or in-actions had resulted in the perception (or reality) of poor care.

Our society has placed doctors, nurses, and other providers on a pedestal (and many providers promulgate this stratification).  Thus, patients routinely fail to question, let alone challenge, providers over care recommendations and activities.  But the problems with our patients simply accepting our care without question are startlingly clear.  If indeed the credo of physicians (and, one would hope, all health professionals) is FIRST DO NO HARM , we providers (myself included) are failing :

  • Between 100,000 and 400,000 Americans are killed via preventable medical errors at the hands of caregivers every year, making incorrect care delivery the 3rd leading killer of adults in the U.S.
  • 10,000 Americans suffer a serious , preventable complication each day, a preventable complication that  is a result of the care we providers deliver. [Expert testimony provided to the United States 2014 Senate Subcommittee on Primary Health & Aging.]
  • 12,000,000 (yes, million) American outpatients are the victims of a provider’s delayed or erroneous diagnosis (when making the correct diagnosis was deemed reasonable).  For half of these (6 million people), that error leads to potentially serious (even fatal) outcomes.
  • The U.S. ranks 37th in overall health performance according to World Health Organization, despite spending greater than 17% of our gross domestic product on healthcare.

My point?  Despite our best intentions, our healthcare system, in which we providers are viewed by the public as leaders , is failing to adequately care for and protect our patients.  I have heard it argued that politicians legislated value-based reimbursement because healthcare stakeholders (including providers) had refused ourselves to tackle our own problems.  While I’m not sure if this is entirely true, we clearly could and can do more to ensure we provide higher value patient care.

The other thing that was apparent to me (particularly from the tweets from hundreds of nurses and a smaller number of physicians) is how far we still have to go.  Virtually all were entirely defensive.  Most blamed me, the patient’s (“you should have called 911,” “what kind of person leaves their mother,” etc. Blaming the patient/family is unrelated to the care provided once a patient arrives at the ER.  Whether via ambulance or personal car, a patient with chest pain must be emergently evaluated per guidelines once they hit the ER door.  Once inside that ER, all care activities are the responsibility of the provider staff (unless the patient is refusing care).  Blaming the patient/family is inappropriate (as in Surgical Morbidity & Mortality Conferences, where blaming “patient disease” as the reason for a patient complication or death is only rarely acceptable).

And many providers simply argued some version of, “we are doing the best that we can.”  And while I believe that they were doing the best that they could that night given what they had (resources), it still was not enough (as they shared that many patients were waiting far too long for emergency imaging studies, and the nurse even said that she “would never want my mother cared for this way”).

All of us must do much more, providers and patients, together .  United, providers are extremely powerful and influential.  Nor does demanding the resources needed to provide the best care have to be a large scale activity:

A surgeon I know well was hired by a renowned academic hospital.  Once there, he found that the hospital had, for financial benefit, entered into an agreement with a surgical suture company that made an inferior product.

He simply refused to operate, telling his new employer that, “I wouldn’t use this suture on my father, so I won’t use it on my patients.”  The battle went on for a month (he performed zero procedures), and they threatened to fire him.  He stood his ground.  Soon, other surgeons began to speak up, empowered by his professional courage in protecting his patients over his career.  That was the proverbial “straw,” and soon the camel’s back broke, as the hospital agreed to purchase the more costly, vastly superior suture for them all.

I truly believe that every provider wants the best for their patients.  And clearly many providers are frustrated, even disillusioned, by their own practices.  Surveys demonstrate this pervasive unhappiness (when asked, only 6% of physicians stated that they were happy with their medical practice).

But we providers are far, far stronger standing together than alone, especially when standing with our patients for what we know is right .  Like my surgical colleague, imagine the power of the ER nurses and doctors at the hospital about which I wrote if they had together demanded that the hospital hire adequate radiology technicians and support staff at weekends and night (cited as the reason so many patients’ emergency studies were routinely delayed at nights and on weekends).  Then my mother would have been whipped off to her carotid ultrasound (which the ER doctor had recommended and wanted my mother to undergo as the next, post-CT emergent study, based on her having suffered > 10 minutes of left arm paralysis).  Imagine all providers joining patients to demand that this hospital hire enough hospitalists to allow the physicians to provide their best care.

Again, I did apologize to both the nurse and doctor at whom I yelled .  They were gracious, sharing that they absolutely understood my frustration over my mother’s care, and that they did not feel personally attacked.  I told them how much I appreciated their attitude, understanding, and words .  To their credit, they acted as representatives of the hospital (even though both shared anger at the hospital administration over resource shortages) in apologizing to me for the delayed care.  I shared that I empathized with their feelings of anger and disillusionment based on my own past career experiences.

As to any editing of the original article and/or removing of comments, this was not my doing.  I feel all comments, even the personally degrading, should be available for others to consider.  After all, “sticks and stones may break my bones…”  What we providers really should be hurt by is not words (even yelling), but by accepting circumstances and limitations that prevent us from truly doing our best to care for and protect our patients.

There are many things that I don't do well (as you have pointed out!), but standing up for patients is something that I am committed to getting right...that surgeon who refused to use the hospital's only suture?  Me.  You may not be able to forgive me for my yelling, but I truly hope you'll join me in demanding that we are empowered to do what we have a calling to do: provide the best patient care.