1. Physician shortage
2. Inequitable physician/surgeon reimbursement
3. What's easier: diagnosis or procedures?
4. Emergency department distractions and interruptions
5. Dealing with hardheaded hospital administrators and nurses
Q: As a legislator, I am serving on a committee that is exploring ways to respond to the current and projected shortage of physicians. I would like your input on what government can and should do to address this issue.
My 15-year-old daughter is avidly interested in becoming a doctor. She found your ER sites interesting and informative, and introduced me to them. I appreciate the wealth of information you give, and I enjoy your refreshing candor. I made a list of the drawbacks of a medical career that you discussed, which will give my colleagues several avenues to explore as we seek to do whatever we can as legislators to make medicine a more desirable career with less long-term potential for physician burnout. Can you suggest others?
Answer by Kevin Pezzi, MD: The primary bottleneck restricting the number of physicians is, as you know, a limited number of medical schools and seats per class. The physician shortage is so acute that a for-profit medical school is now opening in the United States. Building more schools is the easy part; attracting highly qualified applicants is more difficult. However, for the reasons I mentioned in my analysis of our economic crisis, medicine is now a much more desirable profession, and it will remain that way for decades in the future. Once people realize that our current economic woes are no temporary problem, people should begin to appreciate one of the priceless benefits of a medical career: job security. That will increase the number and quality of applicants as the best and brightest students preferentially select medical careers once again.
Addressing the shortage of primary care physicians is an exigency that never seems to go away because politicians, with all due respect, aren't doing nearly as much as they could. For example, although I've been a doctor for many years, I still cannot understand how anyone can justify the current system of reimbursement in which a dermatologist can make more money popping a pimple than I can saving a life in the ER. A plastic surgeon can charge more for a quick and easy revision of a tiny scar than a pediatrician can make for brilliantly diagnosing a baffling condition and taking steps to remedy it before permanent damage is done or the child dies and the parents grieve for years. I could list thousands of other examples, but you know the point I am raising: the reimbursement that doctors receive is inequitably skewed toward non-primary care specialists.
As an ER doctor, I performed many thousands of procedures, ranging from minor (removal of foreign bodies, repairing lacerations, draining abscesses) to major (such as emergency thoracotomy for trauma patients). Based on my own experience and speaking for every physician I know, performing procedures is the easy part of being a doctor. At worst, they require a bit of finesse that is a walk in the park compared to the challenge of diagnosing patients. Many diagnoses are straightforward, but more than a few are not. For example, ER doctors commonly have elderly patients they've never seen before who exhibit nonspecific symptoms. The patient may be weak, tired, dizzy, or nauseated. That could be caused by cancer, anemia, dehydration, a myocardial infarction ("heart attack"), arrhythmia (abnormal heart rhythm), stroke, a medication side effect, malnutrition, food poisoning, pneumonia, a variety of other infections, and many other diseases and conditions.
To compound matters, the patient may have no old records available, no established doctor, may not know the name of her medications and past medical and surgical history, and may have no family members who might fill in the blanks (here's an actual example of a stupid patient that illustrates how nightmarishly difficult it can be to obtain useful information). To top it off, the patient may be very hard of hearing or unable to speak English. There are usually dozens of other patients in the ER, ranging from babies that just cry endlessly to unconscious patients with seizures but no old records or family that might give useful information to help the doc optimally manage that patient without wasting thousands of dollars on tests. (New onset of seizures? History of epilepsy? CNS infection? Fever? Brain mass? Stroke? Drug side effect? Toxin? Hypoglycemia? Electrolyte abnormalities? Pyridoxine deficiency? Trauma? Alcohol related? Genetic disorder? Liver or kidney failure? Where is my crystal ball?)
When I resigned from my position as an attending ER doctor in a teaching hospital to move up north to get more snow (what on Earth was I thinking?), the ER head nurse on my shift said that he would really miss me because I was the best diagnostician he'd ever seen in two decades of ER nursing. I thought, "What? Me . . . the best?" I thought that I was OK and definitely better than some of the numskulls in our department, but hardly as good as I wanted to be (in medical school, you will realize that the more you know, the more you realize that you don't know). He added that he and the other nurses were always more anxious when working with the docs who often couldn't figure out was wrong with patients, because if you can't correctly diagnose 'em, you can't correctly treat 'em, and when nurses see patients slowly ebbing away or crashing before their eyes as the doc looks on in horror and befuddlement . . . well, the nurses become understandably apprehensive.
Most surgical procedures seem grand and glorious, but I could train elementary school students to do many of them and high school students to do all of them. Diagnosing patients requires enormously more education, intelligence, and experience . . . so why do doctors earn so much less for that than for performing procedures? Medical students respond to economic incentives, so what do they do? Preferentially select lucrative specialties dominated by procedures. You can't blame them for that, but you can and should change reimbursement to more fairly apportion the healthcare pie.
While ER doctors are paid more than the average for all specialties, in my opinion they are grossly underpaid, considering how demanding their work is. ER docs treat everyone from infants to the elderly. They must know Internal Medicine, cardiology, endocrinology, obstetrics, gynecology, urology, surgery, radiology, psychiatry, neurology, dermatology, pediatrics, and of course the basics such as pharmacology, pathology, anatomy, physiology, nutrition, histology, and microbiology. They must know how to read EKGs, x-rays, ultrasounds, and CT scans. They must do all of that and more very well, and do it rapidly in an often chaotic environment, often on patients they've never seen before, many with complex, multi-system disease, foot-thick old medical records, and a list of medications so long (one of my patients was on 84 meds) that professors of pharmacology would need hours of analysis to determine if there may be adverse interactions with the current meds or ones administered or prescribed in the emergency department.
Research has shown that distractions and interruptions negatively affect worker productivity. Even something as seemingly minor as an incoming e-mail message has been proven to temporarily discombobulate workers, requiring some time for them to refocus on their original task. ER doctors have so many distractions and interruptions that they can even be interrupted multiple times during an interruption! ER patients are often drunk, on drugs, rude, uncooperative, or even verbally or physically abusive. ER patients usually don't know the ER doc and hence have no bond with him, as they might with their personal physicians, so patients are more likely to sue if their care isn't perfect—or even if it is.
ER doctors may work with topnotch nurses, or incompetent ones who don't give a hoot. I worked with one nurse who went out of his way to sabotage care by touching sterile instruments on a sterile field with his unwashed, ungloved hands while I performed surgery. When I told him to stop that, he excused it by saying that he was helping me, but I never asked for his help or needed it. It's difficult to believe that any nurse would be ignorant enough to do what he did, but he was an alcoholic who'd been fired by GM for repeatedly drinking on the job, according to what other nurses told me. They also said that either GM or the union paid for him to transition into a new career, so he chose nursing . . . a strange choice for such a surly man, I thought. I smelled booze on his breath after some of his breaks, so I wanted to determine his blood alcohol level, but he refused. I brought this matter to the attention of the administrator in charge of all the critical care units (ICU, CCU, and ER), but she dismissed it, saying that it was "none of my business." We had another nurse with Alzheimer's disease, but it took years of pleading with the head nurse to terminate her.
We, as ER doctors, often felt the nursing administration was working against us, not with us. I know that workplace politics can affect any business, even hospitals, but I was surprised at how ridiculous some of those battles were. Things that obviously should have been done were either never done or inappropriately delayed. Perhaps I am biased because I am a doctor, but I don't think such problems would fester if doctors were in charge. Control over hospitals has been wrested away from doctors and given to others, typically business school graduates. Some of these folks are very intelligent people who work well with doctors and nurses, while others are more interested in petty politics, throwing their weight around, stoking their ego, and turning the hospital into a Peyton Place filled with lust, affairs, backstabbing, cronyism, and even crime (for real examples, read my free books True Emergency Room Stories and Love & Lust in the ER).
If you've read all of my ER sites and ER books, you know some of the crap that doctors must now put up with, because we rarely have hiring or firing authority over co-workers. Giving us such authority would improve patient care because recalcitrant nurses would be given pink slips instead of paychecks. For example, when a 21-year-old sophomoric graduate nurse wasted 15 minutes of my time arguing with me in the ER one particularly busy night about whether an EKG was performed correctly, she would have immediately done what she needed to do: repeat the EKG. This young punk had a big head but evidently no ability to read an EKG, which was obviously performed incorrectly. One might think that a person just weeks out of nursing school who hadn't yet obtained her RN license might listen to an experienced ER doctor, but no. Doctors have the ultimate responsibility for patient care, yet we don't have enough authority in hospitals to ensure that patients receive optimal care. Isn't that what it's all about?
However, hospital administrators aren't the only ones who rule healthcare without knowing much about it. I was interviewed by a local radio station (WTCM-AM 580) about universal healthcare and the healthcare proposals of Barack Obama and John McCain. In preparation for that interview, I thoroughly researched their proposals, which largely struck me as being proof that they have little idea on how to deliver better care to more people at lower cost. In the course of that research, I found a source which said that Hillary Clinton shadowed a nurse (that is, followed her around to get an idea of what she did) for 4 hours during the Democratic primary season. That would be laughable if it weren't so tragic. Most of what nurses and especially doctors do is in their heads, so it isn't externally visible. For example, when I diagnose patients, all I appear to be doing is talking with patients and taking notes, but my mind is whirring away analyzing the incoming information and generating a list of differential diagnoses and thinking of what I must do to rule in or rule out the various possibilities. Hillary could look at me and walk away with little idea of what the diagnostic process is truly about.
I recently spent weeks researching the Crash of 2008 because I need to know where our nation is headed so that I can make good long-term business decisions. This analysis suggested to me that politicians who control our economy don't understand it nearly as well as they should. Society doesn't let doctors practice medicine until they pass a long and rigorous educational pathway, yet politicians can rule our economy and everything in it, including healthcare, without having taken a single relevant class. Politicians are often elected because they look nice, have euphonious voices, project confidence, seem compassionate, or promise to give things to people. Too many voters are too easily swayed by such superficial considerations. A post-election poll showed that most Obama voters didn't know:
- Who Bill Ayers, Barney Frank, Harry Reid, or Nancy Pelosi is.
- Which party currently controls Congress.
- Which party advocated "spreading the wealth around."
- That Obama said his policies would likely bankrupt the coal industry and make energy rates skyrocket.
But they did know which candidate (Sarah Palin):
- Could see Russia from home.
- Had a pregnant teenage daughter.
- Had $150,000 of clothing paid for by the campaign.
The people behind the www.howobamagotelected.com site maintain (and who could disagree?) that the mainstream media committed media malpractice in the 2008 Presidential election by focusing on inconsequential matters, such as those pertaining to Sarah Palin, while trivializing or ignoring vitally important information. When I was young and naive, I thought that propaganda existed only in the USSR and similar countries, but for many years, the mainstream media has effectively been a propaganda arm of the Democratic Party. If John McCain had launched his political career in the living room of a man who co-founded an organization that dreamed of brainwashing Americans in "re-education" centers and killing the 25 million they estimated they could not brainwash, you would have heard about it every day. But McCain had no such connection; Barack Obama did (read about it).
That wasn't the only sign of danger in Obama's past. Even after weeks of researching 14 hours per day, 7 days per week, it seemed there was no end to the red flags surrounding him. The deeper I dug, the more I uncovered. If you read my analysis of what led to our financial crisis and how I subsequently expanded on it in my brain teasers page (see items 1, 1a, 1b, and the comments following them), Americans have good reason to be terrified. Politicians do not know how to run healthcare, and most of them do not know how to effectively run the economy. Obama gained the Presidency by appealing to voters with a bumper-sticker level of knowledge about politics, business, and the economy. Unfortunately, our economy is in far worse shape than the mainstream media is willing to admit, so very few people—and even fewer Obama supporters—understand the depths of our predicament and why Obama is not the best one to lead us in these tempestuous times. If our democracy fails, and I think that is quite possible, the primary fault will lie with people who were too distracted by sports or celebrities to pay enough attention to how politicians have done more long-term harm to our country than have every terrorist and enemy nation we've ever faced combined. If that seems unsupportable, what I have to say will open your eyes.