The eulogy of a profession should be a relatively uncommon undertaking. And yet, the death of the physician appears to be such a fait accompli that one feels late to the wake. It has been a long and lingering death, like the proverbial frog in the pot, and but there are moments, increasing in frequency in my day-to-day clinical practice when it seems so sudden, unexpected and even surreal. This essay is an attempt to make sense of that surreal loss and, as such, it is a look back and a reflection upon a bygone era. It is, like all panegyrics, an opportunity for a man to speak well of the past. I dwell upon the spirits of Galen and Osler — and I weep bitter tears. We of this time and of this place; of insidious government mandates and of the idiocy of the anti-vaxxing campaign; of cookbook guideline-enforced medicine and of administrative overlords; of a dehumanizing culture and of mid-level providers and of middling results. We wonder who pulled the trigger and let loose the fatal bullet and as we gasp our final breath, our index finger twitches, as if to say “no one but you. ”
For certainly we, as a profession, have handed over our authority to others, not all at once, but slowly, inexorably, over decades. We are just a shadow of our former selves. Perhaps an argument can be made that we are not yet ostensibly dead, we still employ the use of the besmirched name “doctor,” but we have faded into a background of mediocrity and have become indistinguishable from the administrative milieu that permeates every aspect of a visit to the hospital. Our patients, confused by all the long white coats and nonsensical alphabet-soup titles attached to them, sense this absurdity intuitively.
Where can evidence be found of our demise? Come to any emergency room across the country, and you will see. Come to mine, and I will show you how we treat disease and how we suffer in the modern era. It has the unfortunate distinction of being both unpleasant and unnecessary. At my home institution, we use guidelines driven by government and insurance reimbursement more than common sense. Sepsis has become the purest example of this type of idiocy codified, mandated, and enforced.
Septic shock is an overwhelming infection that has quickly invaded the bloodstream causing fever, hypotension, poor perfusion of the major organs and rapid death. Its obvious features are fever, tachycardia (a fast heart rate), tachypnea (a rapid respiratory rate) and evidence of end-organ damage (confusion, renal failure, liver failure, heart failure, etc.) on both laboratory testing and physical exam (or what still passes as one in 2019). As such, should you arrive with a fever and a fast heart rate, you will quickly bypass the people waiting for five hours in the waiting room and be brought back for immediate IV access, IV fluids, blood work, cultures, antibiotics, and imaging.
Now to the layperson, this all sounds above the board. But ask yourself, how many fevers have you survived thus far without immediate IV access, IV fluids, blood work, cultures, antibiotics, and imaging? I hesitate to be presumptuous but I assume the number is somewhere in the realm of “quite a few.” Undoubtedly, there are some truly septic patients in this mix that will benefit from such aggressive care (they are usually quite obviously ill, even to the layperson) however far too many will receive fourth generation antibiotics for a viral upper respiratory tract infection. Even worse is the overweight patient who arrives exhausted from walking across the hot parking lot. He does not know it, but he has just met sepsis criteria as well. He will be drastically overtreated, much to his detriment, while many patients who are quite sick but fail to meet this or that criteria will be left languishing in the waiting room, egregiously undertreated.
This insane, protocol-driven, misapplication of resources is a daily phenomenon, and it goes by the name of progress. Nurses call me and badger me about writing for antibiotics and fluids and lactate levels immediately for a man with the common cold. I am busy taking care of somebody who is actually sick. I am pulled away from good work to contribute to the bad. If I don’t meet the metric within an hour, the government doesn’t pay for services rendered.
The administrators upstairs will be unhappy. Logic and training be damned!
We’re on a schedule, people. Let’s get on with it. There’s no need to think. Just click that button! My healthy but husky perambulator receives fourth generation antibiotics and IV fluids though he surely doesn’t need the bill or the physical assault. But this is what medicine is now — a knee-jerk reflex to numbers.
We are slaves to absurd algorithms and subsume our intellect and training to the whims of an accountant in an upper-level suite somewhere.
I am ashamed to admit how much influenza (a viral process) I treated this year with broad-spectrum antibiotics. How many allergic reactions, adverse antibiotic effects like Clostridium difficile infections, increased costs or wasted resources that might have been better served on actual sick people were predicated by such ignorant, reflexive medicine? When we ask why should it be so, we are told to stop asking why and to be proud of saving lives. The concept of saving lives seems to have taken on Orwellian doublespeak connotations.
This is nonsense from the same administration that puts seven-minute wait times on billboards around the community when it will be roughly five or six hours until you are seen. Why? Because when you walk into the ER you undergo a brief “medical screening exam” or MSE, per federal EMTALA guidelines. You have your vital signs done and somebody walks by and pretends to acknowledge your existence and then goes and hits a button — and voila! You were seen by a physician in the ER … even if it will be another half a day or so until you are seen by a physician in the ER. Whatever the billboard outside says, add six hours and bring a Russian novel. We’ll get to you soon enough, but by the records of the powers that be (which is really all that matters, your health notwithstanding), you’ve been seen. How’d it feel?
You probably failed to notice. So did we. This is like the old Communist joke where we pretend to take care of you, and you pretend to be taken care of — or something to that effect anyhow. If it happened on a billboard, who am I to protest? And if I, as your ostensible caretaker, cannot register complaints then I promise that you are just a number. And that, right there, is a problem.
Physicians today treat patients like numbers. There are financial reasons for this type of blasphemy, but none of them would hold up in any court of virtue. We’ve given up our profession to bean counters. We are like the Roman senate, or perhaps a better analogy might be our current legislative branch, who forfeited their established powers to, respectively, the emperor and the executive administrative state. As Gibbon writes so eloquently of the relationship between the emperor and the Roman senate in the early empire, and as hospital administrators are currently related to the physicians under their control:
… it may be defined an absolute monarchy disguised by the forms of a commonwealth. The masters of the Roman world surrounded their throne with darkness, concealed their irresistible strength and humbly professed themselves the accountable ministers of the senate, whose supreme decrees they dictated and obeyed.
Thus, the insipid motto of my current emperor: “Above all else, we are committed to the care and value of human life.”
How lovely that sounds in the abstract. But nothing could be less certain in this saccharine, trite and banal motto than the definition of the words “human life.”
One wonders if the words “our bottom line” should be instead inserted.
I should note that I write to you as an enthusiastic supporter of capitalism as a bastion of human improvement and wealth. Long live Adam Smith, but he would certainly not have supported such obsequious nonsense. There are some things that one should not attempt to put a price tag on. Human dignity must surely be one of them.
We’ve allowed our noble profession to be taken over by both the anaplastic leveling shroud of the government and the neoplastic Scrooges of the insurance industry or perhaps both in cahoots with one another. We have been bureaucratized by the “left and commodified by the “right.” For the sake of our profession, and more importantly, for the sake of our patients (whom we will all eventually be one day). We need to wrest control of our calling back to those who earned the honor in the first place. As physicians, we need to be more involved in our destiny. We seem to want to wear the purple but not have to actually legislate. I believe we still want to practice our art, but we’ve abdicated the business of our trade to businessmen, politicians, and lawyers. Consequently, very soon now, we will not have much art left to practice.
A word from Osler on this fragile art of ours:
Who can tell of the uncertainties of medicine as an art? The science on which it is based is accurate and definite enough; the physics of a man’s circulation are the physics of the waterworks of the town in which he lives, but once out of gear, you cannot apply the same rules for the repair of the one as of the other. Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease. This is the fundamental difficulty in the education of the physician …
For the truth of life lies in the minutiae that make us who we are. It’s the sparkle in my daughter’s eyes and the cadence of my infant son’s laughter when I catch him just above the knee. It’s that unique character that we all have, that we long to have recognized by another sentient human being, and search for in our quieter moments. There is not now, nor will there ever be, a protocol or a guideline that will treat my wife, son or daughters in a way that could be even remotely consistent with how much I love them. Medicine is, after all, a labor of love. It is a calling and not a job. It is a life of service rather than a life of servility. It is about the people in your community. The love you give to them is returned immeasurably to the apt physician. You have the chance to become fully immersed in the love of a place — your place. Your home. You become an integral part of that community and are loved as part of the architecture or as the ancient landscape. A point of light in a brilliant and magnificent constellation.
Love of man is erratic, wild, fierce, interconnected and never formulaic because the object of our love is all those things and more-it is a touch of the divine in the dirt. It’s your ancestors, and it’s your great-grandchildren all wrapped up in the present — not completely a memory of things past nor fully an inspiration for the future, but all of those things melded together in tender, fleeting, beautiful moments of joy and heartache. To be a physician is a calling, and it’s a good life. It is a life of the mind, of the sacred, that must, by its very nature, understand our profane mortality, which it studies so assiduously to succeed. It doesn’t need a motto or a goal line or a spreadsheet or some mind-numbing and trite sentiment of purpose. It is already purposeful, individual, small, considerate, evanescent and, at times, seemingly miraculous. It is life in all her myriad expressions summed up in one profession. We haven’t got a protocol for that, and we should never try to make one.
The author is an anonymous emergency physician.
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