The metaphor of boiling the frog has been around a long time and hence may seem a bit tired, but I think it fits the description of what’s happened to physicians in the past 30 years. The term physician burnout is a misnomer, blaming the problem on physicians. What we are really dealing with is physician abuse brought on by the takeover of physician decisions by those seeking to make money rather than provide needed healthcare.
Burnout doesn’t describe what has happened to physicians. Assault on our ability to make medical decisions with our patients does. If the degree of change had been forced upon us 50 years ago in one fell swoop, we would all have objected strenuously, and we would’ve saved our patients and ourselves a lot of misery. Today, with the water at full boil, the assault on providers and the public is much greater than we would have tolerated fifty years ago. The removal of physician ability to make medical decisions for their patients occurred one small step at a time. Physicians didn’t jump out of the tepid water. The water is boiling now and the ability of physician to decide what medical care their patients should receive is dead.
Today, there’s much we tolerate that we shouldn’t. We are supposed to treat suicidal depression vigorously and effectively. If we don’t or can’t, we are liable both from a legal perspective and also from a State Medical Board point of view. Unfortunately, none of those people who are busy judging our care are present at 2 a.m. Sunday morning when we could really use their help.
Furthermore, many patients have dual or triple diagnoses. They may be withdrawing from alcohol or meth and at the same time have suicidal depression. This particular time and day can be difficult because CEOs have cut staff to the bare bones to save money. And nobody wants to take care of these patients because they are a lot of work. In most facilities, the people who can take responsibility for these patients are not around at 2 a.m. Trying to transfer these patients can take three hours and 15 phone calls to reach someone in an appropriate facility. If you finally reach the person in charge at the transfer facility, you are apt to be told that they don’t have the right kind of bed for this patient.
Many nurses simply tell us that they have no plan to participate in the care of this type of patient, or they require the presence of a police officer who will often decline to stay to help. Often, because of the violence, these patients are relegated to the local jail where they at least will be locked up and nobody else will be injured. Caring for these patients requires intelligence, knowledge, experience, patience, skills, and commitment. And in fairness to the law enforcement personnel, sending patients in active withdrawal to jail should never be the only choice for care of these patients. Jails don’t have the equipment for monitoring withdrawal patients and they also can’t give appropriate medication’s for patients who are actively withdrawing.
Often, these patients come to the emergency room with an injury of some sort such as a scalp laceration. Scalp wounds can bleed a lot. You don’t know how much blood loss has occurred before the patient arrives in the emergency room or how hypotensive the patient might become.
So, while I’m sitting in my office repeating the same story to all the receptionists and nurses in other facilities to locate an appropriate transfer of my patient, I also have a sick patient in the emergency room I am supposed to be watching. Every 10 minutes the nurses sitting at the front desk will interrupt my phone calls to tell me that I need to go examine the patient again because somebody, whether it’s the nurses or the ambulance EMT driver, is getting nervous wondering why I’m not spending every minute with their patient.
To add insult to injury, when these patients wake up the next day, they are angry that they don’t have a ride back home. So the next day I have angry friends and families or the ambulance crew complaining that I didn’t spend enough time with their patient in the exam room and I didn’t provide the patient a ride home.
In addition to making many phone calls to many places over several hours, there is the merciless electronic record to deal with. In the six years I practiced at my last rural healthcare desert, I could not get the nurses to prepare an incoming patient’s chart ahead of time. The nurses often didn’t even take the name or phone number of the person coming in. Then there’s the problem of the nurses spelling the patient’s name wrong in the chart, often delaying my ability to make a chart note, see vitals, or order any labs.
When you have somebody who is very seriously injured on the way to the ER in an ambulance, it is common sense to have a chart prepared when the patient arrives. The air ambulance can be called so the patient doesn’t need to spend an additional 30 or 40 minutes in the emergency room waiting for the helicopter to arrive. In the meantime I may be called away from the patient waiting for the air ambulance because two other patients have arrived.
I dread the Monday mornings after a Sunday night like this. I will probably be called into the CEO’s office because the nurses have complained I took too long to respond to somebody’s call or that I didn’t spend enough time with the patient waiting for the air ambulance.
Fixing the kinds of problems I described requires a CEO to create a safe and healthy working environment. At this time, there is very little to stop a CEO from running a hospital like a clucking hen house, where “peers” report on “peers” and staff is fired based upon the rumors of favored tattlers without any investigation of the alleged behavior. Operating a hospital based on rumors of favored informants creates an environment where there are no efforts to resolve problems created by those responsible for addressing systems problems.
The local hospital board is mainly responsible for overseeing the activities of the CEO. And the state is responsible for watching the local hospital boards function according to state directives. To even begin to solve these problems, the states would need to make sure the hospital boards are actually monitoring the conduct of their CEOs and holding the CEOs responsible for creating a safe and effective medical environment, an environment supporting physicians in providing safe and effective care to hospital patients.
It’s time for physicians to jump out of the boiling water and take back the practice of medicine from the profiteers. Direct Primary Care is a start.