Haven't written much in a while, but thought I'd throw in an off-topic post, just for the heck of it. A couple of months ago, I made a major change in my life: I traded in my old car, a 2004 BMW 530i and I went and got a Tesla Model S
12 April 2013
Posted by shadowfax at 9:14 PM
15 January 2013
I may be just a bit late in commenting on this, but last week (which was like ten years ago in Internet time) there was a bit of hue and cry regarding Mayor Bloomberg's report on the matter of prescription drug abuse and restrictions on new prescriptions for painkillers through the Emergency Department.
Initially, I was concerned. I completely agree with the comment from the linked article: “Here is my problem with legislative medicine,” said Dr. Alex Rosenau, president-elect of the American College of Emergency Physicians... “It prevents me from being a professional and using my judgment.” The verbiage used regarding the new rules was worrisome: restricted sharply... city policy ... will not be dispensed ... regulatory authority to impose, and the like.
I'm like most doctors in that even when I agree with the purpose of proposed rules, I quite object to interference in how I practice, to "the government coming between you and your doctor" as it was so memorably put in the past. And given that Bloomberg is getting something of a reputation for being a little dictator I was all ready to get my pitchfork and torches and head down to join the mob.
While I was getting my outrage machine up to operating temperature, I took a moment to read the official press release and the actual source document (PDF), though, and one word in the very first paragraph, notably absent from the press coverage of the proposal, jumped out at me:
Well, that's a horse of a different color, isn't it? Doctors and hospitals are encouraged but not obligated to follow the new guidelines, and in individual cases, the doctor can freely exercise his or her judgement. I'm good with that. So what about the meat of the policy?
Key points that jumped out at me:
- A new/improved database for tracking narcotic prescriptions and making it available to prescribing doctors.
- Not prescribing more than a 3-day supply of most narcotics, and not at all prescribing oxycontin, fentanyl or methadone through the ER, and not refilling these meds
- All narcotics to be electronically prescribed (to limit forged prescriptions)
- Changing the defaults on EMRs to have lower amounts of tablets dispensed.
Frankly, these all seem reasonable, as long as physician discretion is preserved. If someone has a long-bone fracture and won't be into see ortho for a week, well then a week's worth of pain meds is reasonable, for example. In our state, we put forth some very similar guidelines in our "Seven best Practices" for reducing ER overuse and abuse.
The "guidelines" are particularly useful for a practicing doc in that it gives you permission to say "no." Currently, if I see a patient whom I suspect is "working me" for narcotics, but I don't have clear evidence to support that suspicion, I am in a bit of a bind. In such cases, there's no objective evidence of disease — back pain, neuropathy, etc — but that doesn't mean there isn't real pain. If I say no, I run the risk of patient complaints and a letter from the CEO. If I say yes, I then get bogged down in negotiations over how much and what drug. The guidelines offer a compromise: a limited supply of less potent meds. If the patient ups the ante or tries to demand more, I can point to the guidelines and explain that we have a policy, that it's not personal or judgmental, but is simply our "best practice." Even better is that there are clear guidelines against refills and treating of chronic non-cancer pain in the ER. All this is meant to give doctors faced with a demand for narcotics the institutional backing to say no, and tacitly recognizes the fact that doctors have been complicit in creating the problem through excessive opiate use.
I note that endorsing the proposal in NYC was the New York chapter of ACEP, which is also heartening. The problem of ER abuse and prescription narcotic addiction/diversion is a real issue, and it is growing. We, as ER physicians, need to take ownership of the problem, as much as we can, and take leadership in developing measures to mitigate the problem. If we don't, then it is predictable that someone else, likely state governments, will come in and impose solutions on us -- and those "solutions" are likely to be heavy-handed, draconian, and probably ineffective.
So. from what I can tell, New York's approach seems very well-reasoned and hopefully pretty effective. I am also encouraged by an addendum that several private hospitals in the NYC area have announced that they are also going to follow these guidelines (which properly only apply to city-owned hospitals). I'm also particularly pleased that the process we went through in our state has begun to be used as a model for other states to follow!
Posted by shadowfax at 11:39 AM
14 January 2013
Posted by shadowfax at 5:00 AM
25 December 2012
16 December 2012
12 December 2012
Chatting with some med students, a good question was raised: how do we, as doctors, deal with the emotional baggage we encounter in our profession? It's high stress, we see disturbing things, and sometimes we make mistakes that can result in harm to patients. The pressure and responsibility can be very hard to handle.
These stresses, if unmanaged or poorly managed, can carry severe consequences for physicians. Burnout is rampant among docs (and trainees, too). Doctors have high rates of divorce, substance abuse and have the highest suicide rate of any profession.
A normal day at my job is hard: I'm running nonstop for 8-12 hours, I'm constantly interrupted, I have patients making demands of my attention and empathy, I'm saturated with information and need to make rapid decision without adequate information, and I know that if I make an error or miss some important piece of information, the human, professional and financial consequences can be disastrous. It's a pressure cooker.
And that's a day where things go well. A bad day can be very bad indeed. Sometimes it's just the emotional strain of dealing with particularly difficult patients. Maybe you go through a run of giving out terrible diagnoses. Maybe you deal with the death of a child. Or a patient who pulls at your heartstrings in some unique and personal way. Maybe someone dies on you unexpectedly. Worse, maybe someone dies on you and you're not sure if it was your fault or not. Perhaps you know you made an error, and that you're going to have to face accountability for it.
These are the days that drive physicians over the edge. I've had them, and I remember them so vividly even years later. There was the one lady with a gallbladder attack on Thanksgiving, many years ago. She had classic signs and I saw gallstones on my bedside ultrasound. She crashed and died right in front of me from a ruptured thoraco-abdominal aortic aneurysm. Her abdominal aorta had looked normal on my scan; the aneurysm was in the chest and ruptured into the thorax, which is very unusual. That didn't make it any easier to go home and sleep that night.
So I guess my take on the question is not how do we deal with the psychological stress but how should we? I am not an expert, but here are my thoughts.
The first step, which most practicing professionals have already accomplished, is to learn what is called "professional detachment." This is an unnatural skill in which you must suppress your innate sympathy for the suffering experienced by a fellow human being, pain which you may be personally inflicting. The first time you stick someone with a needle, it's probably as traumatic for you as for the patient. More advanced applications involve you ignoring someone's pain or personal tragedy while trying to figure out the hidden life threat. This is a necessary skill if you are to function in the medical environment.
Another way to think of the same skill is to maintain a sense of distance. Remember, an older teaching physician once told me, the patient is the one with the disease. This helps you remember that the patient's condition is not your doing (usually) and their outcome, if negative, is the result of their disease and not necessarily a reflection on your care.
While this detachment is useful and necessary, it can be maladaptive if taken to extremes. First of all, as a physician you do need to express empathy and compassion. It's part of the job. But the emotional demands will be overwhelming if not governed in some fashion; we have limited capacity for caring. My solution is to dole out my compassion and empathy in measured doses, as appropriate to the case and my own mental state. This is not a license to be callous and uncaring in other cases, but rather to be polite, professional and reserved, emotionally.
Furthermore, you need to understand that the professional reserve does not equate to repression of emotion. You suppress it, in the moment, set it aside to get the job done, but that doesn't mean it never happened. For minor stuff it probably is okay to suppress it & forget it. But the bad things — they won't go away on their own, but will fester and bubble up at the most inopportune moments. You need to take some time, when appropriate, to unpack the experience and re-live the emotions to deal with them. Maybe it will be just turning the case over in your head the next day. Maybe it needs to be more immediate. We've sent docs home after bad pediatric arrests when it was clear they were so upset they needed some time. It's essential, in any case, to explore the disturbing feelings so you can come to a resolution and move on.
Many institutions will have formal critical incident debriefings for the entire team, for particularly awful events. While this doesn't need to be performed formally for routine events, it's a good idea to informally debrief with a trusted partner, superior or mentor. Talk through the case, review the medicine and the science, review your actions and outcomes, and your emotional response to the situation. It is helpful to do this with someone you respect, so he or she can give you valuable feedback. This can be over coffee or a beer or three; possibly better that way.
There can be a lot of shame involved when there was a bad case, even when well-handled, but especially so when you know that you made an error or may have. A lot of docs like to bury these as deep as possible. But these in particular are helpful to talk about, and the more publicly the better. This is not easy, but can be invaluable. We instinctively shy away from openly talking about our mistakes, but when you do you will probably receive a lot of support from your colleagues, many of whom have done the same or understand that "there but for the grace of god go I." An additional benefit is that your mistakes may have been due to a system error or a cognitive bias and by reframing the discussion in an educational light, by seeking out the root causes, you can improve the quality of your own care and that of your partners.
Keep a sense of perspective, and try to stay positive. When the job is really getting you down, take a break, go out to the ambulance bay, take a few deep breaths and try to remember the big picture. We have a great job. It's a privilege and an honor to be allowed to care for patients. We can sometimes make a huge difference in people's lives. We have respect and status in society, and are quite well paid for it. Many people would give their right arm to be where you are. Yes, seeing the 10th drug seeker of your shift is a drag, but damn, it's still better than sitting at a desk and moving numbers from column A to column B.
Sublimation is a defense technique that is particularly valuable in the ER. It is a form of displacement where the negative feelings are transformed into something positive, or at least more-or-less acceptable. The most common form it takes is "gallows humor." Tragedy and comedy are deeply linked, and a morbid witticism can provide a lot of relief of the emotional tension that builds up in a clinical setting. Others may channel these feelings into art or literature. To each their own. If this is not your thing, find an outlet. I practice karate, and there's nothing like pounding the hell out of the heavy bag — or a white belt —after a bad day.
Finally, and possibly most importantly, when you know you screwed up, when you know there was an error that harmed or may have harmed a patient: forgive yourself. You are human, as are we all, and we make mistakes. Take the time to understand it, do your best to learn from it, and forgive yourself. Let go of it, file it away, and move on. If you don't or can't, self-doubt and self-hate will paralyze you and in the end it will sink you.
One last thing: if you are really having trouble, get professional help. If you're self-medicating, or if you are bringing work home to the point it's affecting your family, be humble and realize that doctors can benefit as much as (or more than) any other patient from psychological counseling and support. Many hospitals have a confidential Physician Assistance Program, staffed by professional counselors trained to deal with the issues doctors struggle with. I've seen doctors torpedo their careers with behavior and substance issues, and I've seen programs like these successfully rehabilitate physicians who were in a downward spiral. Check with your medical staff office and use the resources that they offer.
Posted by shadowfax at 5:00 AM