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Entries in Emergency Medicine (6)


Hospital Administrators Are Not Always Honest

Guest post by John Di Saia, MD

Hospital administrators have an agenda that's not always aligned with yours.

I used to do emergency work at a hospital in a large chain. It was hardy profitable and became less so over time. When I moved an hour away I sought to limit my emergency exposure for obvious reasons. The hospital administration cited sections of the Bylaws and Rules and Regulations that mandated that surgical specialists take call. This was specified for Plastic Surgery and Orthopedics.

Later and entirely by accident, I found out that the Orthopedists were being paid to take this emergency call by the same administration that was citing those hospital documents. Essentially they were being paid to take call from 15 minutes away whereas I was required to take call for free from four times the distance. Needless to say I dropped that hospital after briefly entertaining legal action. So soon after my divorce I hardly wanted to enrich another attorney. They are much smarter about getting paid than physicians are. I did inform a contact at the local newspaper who passed on the story stating that the public doesn't really care if a doctor gets screwed over. I found that a bit amusing.

As the story evolved I extended my practice up the street not so far away and something similar almost happened again. This time the administration in my new acute care hospital sought to get into an arrangement with me to take call. They were very quick to stipulate that this arrangement was to be secret. It was to involve some kind of payment from the hospital. The thought left a bad taste in my mouth. Emergency call is a loser. I just stopped taking it.

The moral of this story is that you should not expect hospital administrators to be honorable people. Entering into any kind of business arrangement with them especially a secret one is liable to be unfair, unjust or just plain illegal. You might want to avoid that.

About: John DiSaia MD is a plastic surgeon and blogger who also writes at Medical Spa MD.


By Far The Most Common Conversation In A Hospital Is Complaining

By Tamara Moores, a fourth year medical student at Loma Linda University specializing in Emergency Medicine.

They tell me that I’ll change.

They always do.

In our first two weeks of medical school, freshmen students are assigned to shadow senior students working in the hospital. When I was a freshman, my senior student’s final comment to me was “Wow. You’re really enthusiastic… That will change.”

Now as a fourth year medical student, today’s version of the story was – “intern year will change you. You may look the same on the outside, you may portray that same bubbly, sunshine personality, but inside you’ll be different – harder, less tolerant, mean.”

They say it with confidence, they say it with authority, brooking no disagreement, allowing no doubt. Attendings, residents, nurses – they all deign to tell me my future – “there’s no way you can stay that energetic, it’s incompatible with a medical career.” Over and over I have heard this. As a medical student, I am supposed to listen and learn - to be guided by these wise elders. This morning when I heard the prediction for the 100th time, like always I politely listened with a half-smile. Yet silently my spirit roared “How DARE you smugly tell me the fate of my soul?! How DARE you justify your own insecurities about your passionless heart by attempting to degrade mine?”

Medicine is a unique environment. In my short foray into this time-honored, traditioned society, I have been buffered and shocked by the rampant negativity that oozes through the hospital walls. People seem to even take pride in their ability to bemoan their situation.

“Oh God, another consult from the ED, think they managed to even do a physical exam before calling?”

“That professor has no idea what’s on boards.”

“I can’t believe we have to be here.”

“This computer system is a joke.”

By far the most common conversation in a hospital is complaining. Tomorrow, try something different - stop and listen to the myriad people talking at work. The ratio of negative to positive conversations will overwhelm you.

Why is hospital culture like this? Shouldn’t a place of healing be full of warm emotions, positive thoughts, and uplifted people? Why is a ‘negative nancy’ the most common type of medical professional we meet? What are we doing wrong? These questions often come to mind during my workday. There is no easy answer. At the very least I know my top goal is to NEVER become that stereotypical cynical physician, and instead be the uncommon doctor with true passion for medicine.

So how do I accomplish this in such a caustic environment? Have no doubt, even at my current bubbly baseline, it is a daily war to maintain my heart for this career. So many physicians before me have fought this battle and lost. How can I succeed where they have failed?

A resident who I highly respect recently told me ‘be careful what you say, because talk patterns become thought patterns.’ This, more than anything, is my first defense against cynicism. It is SO easy to fall into conversation filled with complaints. These tiny conversations seem harmless, but over the course of a lifetime they shape your soul. Now at the end of my medical schooling, and at the cusp of residency, I am awed by the power of the spoken word. It’s undeniable - what we say both molds and reflects what we think.

Overall I believe the best weapon against developing permanent pessimism is to be deliberate in how we react to daily adversity. How do we respond to a floridly difficult, unpleasant patient? Do we moan about how annoying they are? Do we ruminate about how unfairly they treated us? Permit me to suggest a different response. Instead of focusing on how unjustly that patient has treated me, I instead try to feel gratitude. Whether or not it’s right, these difficult patients make me grateful that my life has not put me in their position. They must be really unhappy inside, to so poorly treat the people who are trying to care for them. When I am mistreated by an attending, I remind myself that they are but a momentary discomfort, and soon will be gone from my life. Over and over I find myself fighting to see the positives in my life. It is a deliberate, intentional strategy, which allows me to shine out with joy even in the little moments of the day.

I firmly believe that working as a medical professional can be a path to a life filled with meaning and passion….if we let it. Not all days are perfect, but most days I feel like I’m the luckiest girl in the world to be in my chosen career. The patients are interesting, my skills are stretched, and I feel fulfilled. Beyond these personal reasons, more than any other career, medicine reminds us how short and precious life is. We deal in broken bodies, lives cut short by car collisions, by strokes, by chronic disease. How lucky we are to be able to move our bodies without wheelchairs, to be relatively self-sufficient. Working in the medical field reminds me daily that everything can change in a moment. It is this acute awareness of the frailty of life, which makes me embrace life with so much abandon. It is this knowledge that gives me joy in the workplace, even during the rough days. To put it bluntly, life is too darn short to be grumpy.

So why am I reflecting via this forum? Perhaps because I hope that I am not alone in this fight. Perhaps I hope that by starting a discussion, we might nudge forth a change in the standard hospital culture. Maybe with forums like this, we can shift the caustic paradigm. Here’s to hope.

About:: Tamara Moores is a fourth year medical student at Loma Linda University. She is specializing in Emergency Medicine.

Read the original post on Uncommon Student MD


ZDoggMD Live Standup: Doctor Comedy

Get your ER comedy fix.

Standup medical comedy from the Mel Herbert’s Essentials of Emergency Medicine 2011. Lame and offensive…well, you really haven’t seen nothin’ yet.

Part 1

Part 2


Emergency Medicine + Perception Problems

I was thinking this week about how Emergency Medicine physicians are perceived in busy Emergency Departments.

For those of you who aren't medical people or don't work in Emergency Medicine, a busy ER is a crazy place.  There is a constant push to make every action more efficient.  Patients are being taken to and discharged from rooms as quickly as possible so the ill in the waiting room can be evaluated.  Activities that aren't completely necessary are eliminated, simply because of the crush of needy people waiting for care.  

There is a mountain of medical literature discussing the issue of ER overcrowding, and a current focus on training physicians to eliminate any testing that isn't absolutely required.  Twenty years ago physicians working in ERs did full work ups on patients.  Today, the focus is on singling out that handful of tests that will give the physician a clear picture of the patient's pathology, so a decision can be made as soon as possible and the patient moved into the hospital or discharged home.  

Now, insert into this chaos two physicians, we'll call them Dr. Flippant and Dr. Effective (for the sake of comparing two styles and nothing more, let's make these physicians both male).

Dr. Flippant walks into a patient room having barely reviewed the chart.  He interacts with the patient in a superficial way, barely asking questions because he really isn't interested.  He does a cursory physical exam, orders no tests, and sends the patient home.  His total time in the patient's room is under three minutes, after the patient waited hours to see him. 

Now let's look at Dr. Effective.

Dr. Effective walks into a patient room having thoroughly reviewed the patient's data.  Because his ER is so busy, he begins his patient assessment the moment he enters the room, guaging the patient for unlabored breathing, ability to move in a symmetric and balanced way, and appropriate responses to questions.  He notes the color of the patient's eyes and skin, the smell of the room, and whether the patient is perspiring.  All these things are taken in within the first few moments of the physician-patient interaction.  Dr. Effective asks a few questions that are targeted, and purposely phrased to limit long responses but give maximum data for his decision making.  He does a focused physical exam, limiting the exam to the body part or parts that will quickly allow him to determine if this patient needs further testing.  Once complete, his very targeted-- yet appropriate and effective-- assessment has determined that the patient needs no further testing, and he sends the patient home.  His total time in the patient's room is under three minutes, after the patient waited hours to see him.

Now here's the problem with the perception of these two physicians...

In each case above, the time constraints limited these two physicians to less than three minutes with their patients.  However, one of these examples was a flippant, sloppy physician and the other was an effective and appropriate physician.  

The difficulty is that if you're the patient in the room, it's almost impossible to ascertain which example is treating you.  Both spent little time at your bedside.  Both asked few questions.  Both did limited exams, and neither ordered any tests.

Now, if you couple this with the confounding variable that Dr. Flippant is a charming, visually appealing person, and Dr. Effective has a more curt personality and frumpy look, the perception issue becomes even more difficult.

To the untrained eye, these physicians did the exact same thing with both their patients.  The difference between these physicians was the processing that was going on internally.

Even an excellent physician-- working efficiently and effectively taking care of a large number of patients-- in a busy ER  frequently gets feedback from patients and families that he "didn't spend time with me" or he "wasn't interested in my problem" or he "didn't even order any tests." It is difficult to explain to these idividuals that the physician was actually acting appropriately, when the patient is incensed that after their long wait time "that's all the doctor did."

What's worse, if you're the patient, you have really no way of determing which doctor took care of you.  How can you be assured that you saw Dr. Effective and not Dr. Flippant?  The unfortunate thing is that unless you have medical training or a medical family member interacting with the physician, it's almost impossible.

In my view, this is one of the most difficult issues in contemporary Emergency Medicine-- the very subjective and often skewed perception issue.  It's unfortunate, and it's a big problem for patients, and for the good physicans out there trying to take care of them.



International Medical Corps Jobs

Emergency response volunteers, internships and fellowships from International Medial Corps.

The International Medical Corps has a number of nonclinical physician jobs listed on the Freelance MD jobs site.

Listings include:

  • Emergency response volunteers
  • International Emergency Medicine Internships
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  • Emergency Medicine Specialist, Afghanistan
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You can see all of the listings and learn more here:


ER Doctor Feels "Used"

Emergency Medicine in the United States is at a breaking point.

Emergency Medicine News published an editorial  recently by Dr. Edwin Leap, an Emergency Physician living in South Carolina. Dr. Leap writes an article that could have been written by any person working in any of the many Emergency Departments in the United States. You can read the full article here .

In the article Dr. Leap discusses how those in Emergency Medicine are manipulated and used by "evil" people who work the system in an attempt to get free housing, free food, and/or narcotics. He also discusses how the government and other groups in medicine abuse the Emergency Department, using it as a means of working up patients to be admitted or as a place to initiate the latest bureaucratic policy.

Emergency Departments around the country are overrun by patients and understaffed. Doctors and nurses working in our nation's Emergency Departments are expected to save the lives of critically ill patients while soothing the egos of the unsick waiting in line for a bed. Patient outcomes have been replaced by satisfaction scores as the means of evaluating caregivers, and good men and women are being driven out of the specialty by burnout, injury, lack of appreciation, and abuse (both verbal and physical).

I appreciate Dr. Leap's honesty and hope that policy makers are listening. For those unsung heroes slogging it out in our nation's Emergency Departments, thanks for your efforts.

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