Blame the Physician

Being in healthcare, one tends to hear everyone's personal stories of medical misadventures, clinical or not. Often, there's at least the implied question: You're a doctor, so you know how things work - why did things go so wrong for me?

So I recently heard the tale of a case of cellulitis - advised by primary physician to go to an ER for IV antibiotics - leading to a day and a half of abuse for the patient in question. None of the details would surprise you, as I'm sure you've heard it all before: Patient sat around in the ER for eight to nine hours despite getting there first thing in the morning. Members of staff were clearly not communicating with one another. Patient finally admitted only to be parked in a ward hallway with other patients due to lack of beds in actual rooms. Patient ignored by nursing staff, whether for help in using the bathroom or to obtain some form of sustenance, having been given nothing for the preceding 12 hours. Patient's medical details discussed, in the hallway, within earshot of multiple others. I could go on.

I'm sure the unkind treatment would have gone on, too, but the patient finally could take no more and, in tears, managed to get the nurses' attention to try signing out AMA.

Well, this was finally something worthy of action - perhaps even one of those (gasp) "never" events. With surprising speed and efficiency, a ranking physician and a hospital administrator appeared on the scene, and multiple issues were put to rest at once, including, at last, the furnishing of food for the famished.

And an interesting keepsake to go with it: A special card for the patient to keep, permitting bypass of the ER and direct admission in the future. I must admit, I have never heard of such a thing, and am looking forward to eyeballing it.

That "get out of jail free" token is, to me, the smoking gun of the story. The fact that the admin saw a need for such cards to get printed, and carries them for distribution, tells me that the admin knows the system is broken. And rather than fixing the breakage, these cards are used as band-aids for patients who sufficiently complain, or otherwise come to the attention of the admin. Other patients encountering the numerous flaws within the hospital are effectively shrugged off as acceptable losses.

The doc was there for show. He wasn't the one distributing skip-the-ER cards; when was the last time you saw a physician without administrative title wielding that kind of power? The docs didn't even have the ability to get the patient fed until the administrator came along. Not that they didn't try. The nearly-tearful patient, an hour or two prior, had called to a passing intern, begging for some intervention. The intern returned from the nursing-station with a bell (the kind you'd see at a hotel's front desk), since the patient's hallway-spot did not have the nurse-call button found in the actual rooms. Of course, the intern had initially balked, saying that this was "nurses' work."

Why do I say "of course?" The intern is clearly learning the role of a doctor in our modern healthcare system - to be a cog in the machine, in charge (at least, for now) of diagnostic evaluation and selection of therapeutic plan, but no more than that. Certainly not of telling nurses to get the patient some damned food, orderlies - sorry, PCAs - to move the patient out of the ER and into the damned ward, etc. Try to exercise authority over anyone other than your own junior house staff, and you're at risk of write-up for your "disruptive" behavior. At best, you risk being revealed as a powerless figurehead when they shrug and tell you anything from "I'm on break" to "ain't my job." Which is not all that far removed from the intern's attitude.

In our politically correct society - where it's practically a constitutional right for everybody to feel like a winner with soaring self-esteem and nobody must feel less important than anybody else - the notion of a physician as genuine leader of a healthcare team has fallen into disrepute. We've hung on to the notion of the doctor being accountable, when things go wrong - that's the real reason the administrator brought the doc along with him.

It's handy to be able to blame somebody, and not just for the ambulance-chasers; politicians make a lot of hay accusing doctors of being inefficient and wasteful, and endlessly hacking at our reimbursement for such sins, while denying us the tools to remedy them.

Maybe the blame game will never get played out. If and when it does, and real improvements are desired, look no further than the medical school graduates struggling to make our patchwork system as non-dysfunctional as possible. They're trained for this sort of thing, and might just have a few ideas.