1. Sleep (& fun) deprivation in medical education: contrary to Maslow's hierarchy of needs
2. Starting an ER group or Urgent Care Center
by Kevin Pezzi, MD
This topic is a continuation of Working part-time as an ER doctor/Doing the right thing. I will intersperse my replies:
Q: I really like the idea of starting my own ER group. I imagine that it would require less overhead than opening my own urgent care facility.
A: Definitely. Hospitals supply virtually all of the equipment and staff (other than ER doctors) required to run an emergency department. Urgent Care centers require less of both, but the costs are still substantial. The big drawback to having hospitals hire and pay nurses, assistants, clerks, and various technicians is that you can't fire them. That can be a nonissue if you work at a hospital with wise administrators, or a nightmare if the brass operates on the too-frequent “warm body with credentials” criteria for deciding whom to hire and retain.
As I mentioned in other topics on this site and ERbook.net, I worked at some hospitals in which I harmonized with the staff as if they were beloved sisters and brothers, but I also worked in places where some of the staff were atrocious, stemming from less intelligence, knowledge, dedication, or conscientiousness, which is absolutely vital for everyone who works in healthcare.
What particularly amazed me was how administrators at some hospitals seemed oblivious to the wide bell curve of competence, with some genius nurses who were all-around wonderful working in the same ER as others who were malicious sociopaths fighting doctors any way they could, any time they could. Then there was the nurse with Alzheimer's disease. We told administration about her for years before they finally listened.
Q: I had actually wondered if it were possible for an EM doc to start his/her own group. This idea is quite interesting. I guess that means that my group would be responsible for securing it's own EM contracts with hospitals. I wonder how difficult that would be. How much politics are involved, etc.?
A: That depends upon the hospital. Some administrators are commendably straightforward, emotionally mature, and know how to get the best out of people: the most essential skill for any leader.
On the other hand are administrators who are goofy, immature game-players, such as the person I described in my first ER book and various ER website postings. She was the director of the Critical Care units (ER, ICU, and CCU), but I never understood what the even-higher big shots saw in her, other than great legs, which she loved to flaunt by wearing the shortest skirts I've ever seen in hospitals other than on hookers.
That's right—not even one of the thousands of teenage girls I saw in the ER wore a more revealing skirt or dress despite the fact that women of that age tend to show skin as a way to entice mates. When even teenyboppers are dressed more conservatively than the Critical Care director, one might conclude, as I did, that she had a screw loose or at least was immature and inappropriate. A hospital is simply not the place for showing skin.
To illustrate her lack of qualifications, the Critical Care director seemed not to know, for example, that pulse oximetry is not a full substitute for arterial blood gases, and seemed not to care that a combative nurse was likely drinking booze on his breaks. That wouldn't have been a problem if alcohol wore off within 15 minutes, but it doesn't, of course.
Other nurses told me the boozer was fired by GM after repeatedly drinking on the job, so (probably as part of some UAW program) they paid for him to attend nursing school as a way to get rid of him. Since when is healthcare a good refuge for alcoholics?
BTW, my brother later married a woman who was married to Ben Hamper when he wrote Rivethead: Tales from the Assembly Line, a bestseller that detailed alcohol and drug use, coupled with a “screw the employer and their customers” attitude that made the subsequent GM bailout very predictable.
Rumors were that the Critical Care director was sleeping with the hospital CEO (who had ethics Hitler would have approved of, if what my boss told me about him was true), who was later dismissed by the hospital board along with Miss Hot Legs and the other rotten apples I'd lambaste during hospital meetings because I loathed their judgment. The board evidently did, too. Once they cleaned house, that hospital flourished.
Regarding EM contracts with hospitals: My former boss (the one mentioned in my first reply to you) could help you with that. Speaking of him, here's a relevant tidbit: One day he asked me to meet him at the airport so we could fly in his plane to meet the CEO of a hospital looking for a new group of ER doctors. He and that hospital were gems, as were the CEO and staff of another hospital I worked in. If I get rich, I will give them a pile of money. I will be less generous with the local (supposedly) Top 100 hospital and attach strings to my donations so some staff members get the educational (examples 1 and 2) and mental help they need.
After my Mom was diagnosed with metastatic bladder cancer, she had a problem with her vagina, which might indicate extension of the tumor or some more common problem. I asked her doctor if she'd done a pelvic examination to see what was wrong, but she hadn't (making me wonder if she were lazy or incompetent); she suggested that I do it (proving that she was twisted).
When I accompanied my critically ill Aunt, complaining of severe shortness of breath and chest pain, to Munson Medical Center's ER, I suggested that the nurse give her oxygen, which angered him so much he forcefully threw the oxygen mask at me, striking me so hard that the impact area stung for more than an hour later.
I wrote a letter to Ed Ness, Munson's President and CEO, and spoke on the phone with him. He was nice enough to call, but during our long conversation, he made it clear to me that his only goal was to sweep the problem under the rug. He also said the nurse who struck me was still working in their ER. This made me question his judgment because I didn't want financial compensation or even a free meal ticket for their cafeteria; I wanted an apology by the nurse and an explanation for why he felt justified in doing it. I wondered if the nurse were an alcoholic or on drugs, or if he had some stressful event in his life that made him snap: a straw that broke the camel's back.
Think about it: if my allegations were not true, the nurse could have sued me for millions of dollars. I wouldn't take that risk (even if I were unethical enough to do that, which I'm not) just to get an apology and explanation for the assault—if that didn't occur, an apology and explanation for it would be utterly meaningless and an egregious waste of time. If Mr. Ness had common sense, that would have immediately occurred to him.
For all I knew, they may have had closed-circuit TV that could have proven what happened, but I didn't need to worry about that, because it did. If I were that hungry for money, I wouldn't have paid a programmer in India (working for me around that time) twice what our contract specified. Nor would I offer to give free meals, free firewood, and even free microhomes. As my girlfriend can attest, I am always looking for excuses to give money to people; she thinks I am too generous—basically a sucker, but she is too cultured to use that word.
Q: I'm an entrepreneur at heart and have a company called ---------.
I'm also an educator by nature and training. I have an Ed.D. in Adult Education and Organizational Learning but I want to make more meaningful contributions to the world through medicine. It has left my hubby a bit stumped but he's starting to come around and open up to the idea of medical school, residency and ultimately more sacrifices on all of our parts, including my 2-year-old son. Yes, the plot thickens.
I'm an out-of-the-box thinker and also a glutton for punishment :-). I'm hoping to do meaningful work that truly changes people's lives while having a high quality of life so that I can spend important moments with those who I love the most, my family. Family bonding, working out, camping trips, picnics in the park are activities that are extremely important to me. Why can't I work hard at work while saving lives without having to give up my holidays, weekends, and family dinner times, too? In everything (except medical school and residency, of course) there needs to be balance. It makes us better service providers, kinder spirits, and all-around more effective at the many different roles that we have to juggle (especially as women).
How will we ever reach our highest potential if we spend decades with sleep deprivation working an abundance of crazy and sporadic shifts in the ER? Maslow's hierarchy of needs clearly identifies sleep as a basic need.
I'm committed to becoming the very best of who it is that God has created me to be in every aspect of my life. Call me an optimist but self-actualization is more than just a lofty concept for me. It's a living and breathing ideal that's attainable and worth striving for even as an EM physician or within any specialty area for that matter. Perhaps creating my own EM group with these values as well as solid business acumen would put me on the right path.
A: Wow. Medicine needs you. Ever see the movie Doc Hollywood? There's a scene in which Dr. Benjamin Stone (“Hollywood,” portrayed by Michael J. Fox) is being interviewed by a potential employer, Dr. Halberstrom, who received a letter of recommendation from Dr. Aurelius Hogue, a lovable down-to-earth curmudgeon. Hogue said that Halberstrom would be a “bovine, clodpated, citified moron” if he didn't hire Stone on the spot. Similarly, medical school Admissions Committees would be dang foolish to not accept you.
After many years of interacting with thousands of people who aspire to become doctors, you clearly stand out. I wish I had your wisdom, and I wish more medical educators had it, too. Especially during the medical education process, there is a pervasive imbalance in basic human needs, such as the sleep and recreation you mentioned, that drains the humanity out of doctors, after which medical establishment leaders are shocked that doctors aren't more humane, kind, and genuinely caring.
Sure, we're taught to act as if we have empathy, but I don't recall ten seconds of advice on how to kindle genuine, heartfelt empathy. Perhaps the assumption is that it cannot be created (wrong; it is easy to do) or that patients are unable to differentiate ersatz emotions from real ones, but they can—just as customers can easily sense the difference between genuinely nice waiters and waitresses from ones who put on an act hoping for a bigger tip.
Beat a nice dog long enough and it won't be nice. After beating medical students, interns, and residents for years, it is no wonder that many of them are depressed, emotionally withdraw, bitter, and focused more on money than patients.
During my medical school admission interview, the doc who was the pediatric ICU director told me he expected students to work from early morning to late night seven days per week except for an hour-long date once per week.
At that time, I thought such stellar doctors were basically God's right-hand men, and any such statement was basically a commandment from God to do the right thing. So I did what I thought I was supposed to do. I forgot about my girlfriend (until she poured a large bowl of sugar on my head—true story), and I forgot about my hobbies of snowmobiling, guns, and electronics—building electronic devices put me on cloud nine.
I don't know how I did it; it was as if a switch had been flipped in my mind. One day I was obsessed with snowmobiles, the next I could be in a blizzard and not even think of them for a split-second until years later when I was a licensed doctor—that's like a teenage boy not thinking about women while walking on a beach filled with them dressed in bikinis. I was focused on medicine as if that were the only thing that mattered. I thought I was doing myself and my future patients a favor, but what I was doing was becoming more of a robot.
It took years after I left clinical medicine to become a nice person again. I never lost all of my humanity, but in retrospect I was too much of a jerk after being worn down by chronic insomnia exacerbated by objective tinnitus and trying to be a perfectionist in a busy ER, which is like trying to make a home full of kids and clutter ready for a Martha Stewart inspection in five minutes or less.
Putting “MD” after a person's name does nothing to diminish his or her requirement for the basic human needs you wisely mentioned. People need downtime to recharge their batteries even if their jobs aren't stressful, such as my current job working as an inventor. Most of my big ideas come when I give my mind the freedom to wander by driving a tractor, playing with my chickens, mowing my lawn, cutting up trees with my chainsaw, building a shed, doing dishes, or vacuuming. Sometimes even writing, which is one reason I do so much of it. :-)
Play, and fun in general, is essential for people of all ages. There doesn't seem to be hardly any time for fun during medical school and residency, but that's because their educational process is horrendously inefficient. What medical educators are doing is so shortsighted and irresponsible that it should be a crime, but medicine is a hidebound profession that reveres antiquated educational practices. Updating the process would free plenty of time so that even nose-to-the-grindstone students would have time for fun, sleep, families, and friends. Ultimately, it would be better for doctors and patients because when the former become burned out and lose some of their humanity, the latter suffer.
In conclusion, I'd like to thank you for bringing up Maslow's hierarchy of needs. I've seen the truth of it in my life: after my more basic needs were met, I became more ethical and creative, and much better at putting myself in the shoes of others, which is a simple but effective way to enhance empathy.
Interestingly, this personal change was so profound that it affected some of my political beliefs, which I thought were cast in stone. This is one manifestation of how the mind is plastic—that is, able to effectively rewire itself to improve. Researchers found extensive evidence for this regarding other cerebral functions, but it also applies to personality and behavior. To reduce recidivism without coercion (which has limited effectiveness), prison systems should implement ways to favorably modify behavior, but they are woefully behind the times, just like the medical education system.
In another article initially focused on physician income versus lifestyle, I discussed how researchers working with John Robison helped him overcome his (difficult to treat) Asperger's syndrome, one manifestation of which is limited empathy.
More empathy would make this world a much better place. Coincidentally, after writing this article, I turned on my TV while eating and saw a program detailing how Rosie Alfaro murdered a friend's sister, 9-year-old Autumn Wallace, by stabbing her 57 times so she couldn't report how Alfaro stole things from the Wallace home that netted her $240. Slicing up a child for such a paltry amount, or even for all the money in the world, is a manifestation of the lack of empathy that is a hallmark of sociopathy.
However, most people, not just sociopaths, have less than ideal levels of empathy. That is easily augmented, but rarely taught. Instead, teachers and parents usually give instructions on how to appear empathetic, as medical schools do. However, placing band-aids on problems like lack of empathy and racism (which results from innate xenophobic tendencies given free rein by a shortage of empathy) is just a cover-up that doesn't do nearly enough. For proof, just look at the messed up world.
Why overly intense training is counterproductive
With evidence that stress and depression can shrink the brain, putting medical students and residents through the wringer is clearly counterproductive. Had I been in charge of my educational process, I could have learned much more than I did. Some readers may think that isn't a valid concern since I graduated in the top 1% of my class, but I know that I and others could have learned more and performed better as doctors had the professors in charge of our training considered the scientific evidence proving that what they imposed on us was just plain stupid and so unconscionably negligent they should be sued for professional misconduct. Educationally, they were not in the 21st century or even the 20th century; they used antiquated methods that harm patients, but like most powerful people, they go through life with blinders on, oblivious to what they're doing wrong.
PS to Joi: I took your advice yesterday afternoon: I worked on a shed and played with my chickens, who I call my darling little babies! :-)
Readers other than Joi: If you haven't already done so, you might want to read the topic (Working part-time as an ER doctor/Doing the right thing) that led to this one.
In Not everyone is corruptible, I discussed how researchers found that high-power individuals are more likely to have less compassion and empathy in their interpersonal relationships.
- Physician's Empathy Directly Associated With Positive Clinical Outcomes, a Large Study of Italian Diabetic Patients Confirms based on The Relationship Between Physician Empathy and Disease Complications: An Empirical Study of Primary Care Physicians and Their Diabetic Patients in Parma, Italy
- Physician's Empathy Directly Associated With Positive Clinical Outcomes
- Showing Empathy to Patients Can Improve Care
- New molecular target key to enhanced brain plasticity based on The NAP motif of activity-dependent neuroprotective protein (ADNP) regulates dendritic spines through microtubule end binding proteins
- American cities are many times brighter at night than German counterparts
Comment: With everything else being equal, based on that American city dwellers likely have more sleep problems because most people—oblivious to the hazards of light pollution—don't use completely opaque shades, blinds, or drapes to block all light entering their bedrooms.