Gather round kids! Let Grandpa Doctor Leap tell you a few things about the old days of doctoring in the emergency room:
Back in the good old days, medicine was what we liked to call “fun.” Not because it was fun to see people get sick or hurt or die, but because we were supposed to do our best and people didn’t wring their hands all the time about rules and lawyers. Sometimes, old Grandpa Leap and his friends felt like cowboys, trying new things in the ER whether we had done them before or not. Yessiree, it was a time. We didn’t live by a long list of letters and rules — we knew what was important. And we were trusted to use our time well, without being tracked like Caribou with electronic badges. Those were the salad days.
When I was a young pup of a doctor, we took notes with pen and paper and wrote orders on the same. It wasn’t perfect, and it wasn’t always fast. But it didn’t enslave us to the clipboard. We didn’t log-into the clipboard or spend twenty minutes trying to figure out how to write discharge instructions and a prescription. We learned in grade school. EMR has brought great things in information capture and storage, but it isn’t the same — or necessarily as safe — as the way humans conveyed information for hundreds, nay thousands of years.
Back then, kids, the hospital was a family! Oh yes, and we took care of one another. A nurse would come to a doctor and say, “I fell down the other day, and my ankle is killing me! Can you check it out?” And the doctor would call the X-ray tech, and an X-ray would get done and reviewed. The doctor might put a splint on it or something, and no money changed hands.
In those days, a doctor would say to the nurse, “I feel terrible, I think I have a stomach bug!” And she’d say, “Let me get you something for that.” And she’d go to a drawer and pull out some medicine (it wasn’t under lock and key) and say, “Why don’t you go lie down? The patients can take a break for a few minutes.” And she’d cover you for 30 minutes until you felt better.
We physicians? There was a great thing called “professional courtesy,” whereby we helped one another out — often for free. Nowadays, of course, everybody would get fired for that sort of thing because the people who run the show didn’t make any money on the transaction. And when you have a lot of presidents, vice-presidents, chief this and chief thats — it gets expensive!
When medicine was fun, a nurse would go ahead and numb that wound for you at night — policy or not. And then they’d put in an order while you were busy without saying, “I can’t do anything until you say it’s OK, or I’ll lose my license. Do you mind if I give some Tylenol and put on an ACE? Can you put the order in first? And go ahead and order an IV so I won’t be accused of practicing medicine?” Yep, we were a team.
There was a time, children, when doctors knew their patients and didn’t need $10,000 in lab work to admit them. “Oh, he has chest pain all the time, and he’s had a full work-up. Send him home, and I’ll see him tomorrow,” they might say. And it was glorious to know that. Or I might ask, “Hey friend, I’m really overwhelmed, can you just come and see this guy and take care of him? He has to be admitted!” And because they thought medicine was fun too, they came and did it.
In those sweet days of clear air and high hopes, you could look up your own labs on the computer and not be fired for violating your own privacy. (Yes, it can happen.) You could talk to the ER doc across town about that patient seeking drugs and they would say, “Yep, he’s here all the time. I wouldn’t give him anything.” And it wasn’t a HIPAA violation — it was good sense.
Once upon a time, we laughed and we worked hard. Back then, we put up holiday decorations, and they weren’t considered fire hazards. We kept food and drink at our desks, and nobody said it was somehow a violation of some ridiculous joint commission rule. Because it was often too busy to get a break, we sustained ourselves at the place we worked with snacks and endless caffeine, heedless of the apparent danger that diseases might contaminate our food. We had already been breathing diseases all day long and wearing them on our clothes. Thus well fed and profoundly immune — we pressed on.
In those golden days of medicine, sick people got admitted whether or not they met particular “criteria,” because we had the feeling there was something wrong. We believed one another. Treatment decisions didn’t trump our gut instincts. And “social admissions” were not that unusual. The 95-year-old lady who fell but didn’t have a broken bone and didn’t have family and was hurting too much to go home? We all knew we had to keep her for a day or two, and it was just the lay of the land.
I remember the time when we could see a patient in the ER and, because my partners and I were owners of our group, we could discount their bill in part or entirely. We would fill out a little orange slip and write the amount of the discount. Then, of course, the insurers insisted on the same discount. And then nobody got a discount because the hospital was in charge and everyone got a huge bill, without consideration of their situation. The situation we knew, since we lived in their town.
Back when, drug reps left a magical thing called “samples.” Do you remember them, young Jedi? Maybe not. Young doctors have been taught that drug companies, drug reps and all the rest are Satan’s minions, and any association with them should be cause for excommunication from the company of good doctors. But when we had samples, poor people could get free antibiotics, or antihypertensives, or all kinds of things, to get them through in the short run. And we got nice lunches now and then, too, and could flirt with the nice reps! That was until academia decided that it was fatal to our decision-making to take a sandwich or a pen. Of course, big corporations and big government agencies can still do this sort of thing with political donations to representatives. But rules are for little people.
When the world was young, there was the drunk tank. And although mistakes were made, nobody pretended that the 19-year-old who chose to a) go to the ER over b) go to jail, really needed to be treated. We understood the disruptive nature of dangerously intoxicated people. Now we have to scale their pain and pretend to take them seriously as they pretend to listen to our admonitions. They are, after all, customers. Right?
These days, we are perhaps more divided than ever. Sure, back in Grandpa Doctor Leap’s time, we were divided by specialty and by practice location; a bit. But now there’s a line between inpatient doctors and outpatient doctors, between academics and those who work in the community, between women and men, minorities and majorities, urban and rural, foreign and native-born and every other demographic. As in politics, these divisions hurt medicine and make us into so many tiny tribes at work against one another.
And finally, before Grandpa has to take his evening rest, he remembers when hospitals valued groups of doctors — especially those who had been in the same community and same hospital for decades. They were invested in the community and trusted by their patients and were valuable. Now? A better bid on a contract, and any doctor is as good as any other. Make more money for the hospital? In you go and out go the “old guys,” who were committed to their jobs for ages.
Of course, little children, everything changes. And often for the better. We’re more careful about mistakes, and we don’t kick people to the curb who can’t pay. We don’t broadcast their information on the Internet carelessly. We have good tools to help us make good decisions. But progress isn’t all positive. And I just wanted to leave a little record for you of how it was, and how it could be again if we could pull together and push back against stupid rules and small-minded people.
Now, Grandpa will go to bed. And if you other oldies out there have some thoughts on this, please send them my way! I’d love to hear what you think we’ve lost as the times have changed in medicine.
Grandpa Doctor Leap
Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of the Practice Test and Life in Emergistan.
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