Doctors show up. Until they won’t anymore.

There are many jobs where people work long and hard. But I will assert that none train as long and hard, and at so much expense, as doctors/surgeons that manage the emergencies for their specialties and take night call, on top of managing a full-time practice.

The key point I am trying to make is that doctors, as a profession, basically agree to “show up.” That is what sets us apart in the eyes of our patients.

Not only do we show up, but doctors also agree to show up for people who do not, or cannot even pay us, yet still can sue us if they find fault in our work.

I have done the math, and since I turned out as a fully trained surgeon in my specialty in 1991, I have easily given away over $1M worth of free care and have spent the equivalent of over eight continuous years on call for emergencies, mostly at a level 2 trauma center. That is on top of my 50 hours a week of bread and butter practice.

I have never asked for, nor received one thin dime from the said hospital for that duty. That is because either I am stupid or I do it for the patients.  I say it’s the latter. Also, I am proud to say I have never worked for a hospital, although they have profited handsomely from my dedication to patients, I assure you.

Additionally, since what I do involves my personal time for my personal services, I cannot even write it off of my taxes.

Doctors also set aside huge blocks of personal time when, even if we are not asked to show up, we need to be immediately available to show up if called. That means we give up our freedom during those times. Our families feel that pain too, when showing up for patients means not showing up for your loved ones.

There is a federal law that says doctors have to show up if we service a hospital with an ER, and our specialties are needed for emergency care. That law is EMTALA.  It has been in effect since 1986.

To my knowledge, EMTALA is the only Federal law in existence that compels a private citizen (a doctor) to show up when called, at any time of night or day, to deliver a professional service, without any expectation of getting paid. Further, we can be sued, should the outcome be unsatisfactory in any manner. And if that doctor refuses to show up, they will face large fines and occasionally criminal charges.

EMTALA says if I don’t show up when I’m expected to, I can be fined $50K minimum and could even face jail time for negligent manslaughter if my refusal to show up led to someone’s death.  That has happened more than a few times. Even a time or two when the doctor didn’t know they were supposed to show up.

Juries take a very dim view of doctors who don’t show up when they are expected to.

The quid pro quo has always been that doctors should expect to have a generally tolerable work schedule, and make a good living, financially.  A “tolerable work schedule” is a loose term as doctors are famous for long work hours.

That good living would include: To be able to manage education debt, buy a house, raise a family, and have a comfortable retirement. In many ways, similar to a good union job in the ’50s, ’60s, and ’70s.

In trade for that expectation, we are always there for the public when they need a doctor. But the public needs to know, that is no longer the case, because the cost is too high, and the work schedule is becoming increasingly intolerable.

In the relatively near future, you will see that not enough capable doctors are showing up. They are instead looking, and finding something they can live with, usually still medically related, but without the pressure of having to show up.

One of the chief strategies of doing this now is for a doctor to be paid by a hospital as a contract worker, who will work a set 12-hour shift. Under that arrangement, the doctor is held harmless for not showing up outside of their designated shift, and clear delineation as to when they work and when they will be free again. But this only works at big centers.

Doctors not showing up has already started in places all over the country where smaller hospitals have closed their emergency rooms because they cannot get doctors to work there. Without an ER, the laws that force us to show up mostly no longer apply.

It is a shame it is coming to this. It didn’t have to be this way. Some areas of medicine are still quite tolerable for doctors. But to those doctors, it’s the kind of work that will not place them in a position that they have to show up, “or else.”

The trust has been broken, and I suspect irrevocably. And it was not by us doctors. I saw it happen with my own eyes during my own medical career, which began the day I walked into medical school, in the fall of 1982.

The dean of students, quite the jokester, paraded dignitaries past us for two hours in the main auditorium, who proceeded to tell us what patients would expect and rightfully demand of us as their physicians, now at the start of this noble endeavor.

The dean was the last. He asked for silence. He dimmed the house lights and asked us all to close our eyes, lean back, relax in our chairs and take a few deep breaths. We happily complied.

He then spoke softly, saying that in about a minute, our first official lecture will begin, and he wanted us to remember this moment, because when that lecture starts, we will be “behind” for the rest of our medical careers, showing up for our patients who need us.

They still need us more than ever. Whether we will continue to be able to “show up” depends on fixing what is broken in American health care today.

Nick Benton is an otolaryngologist.

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