Dirty Laundry

Sharing many characteristics of humans, doctors can be assholes. Petty, venal, vengeful. Excessively political, and narrow-minded. I don't exclude myself. Here's how some of it goes. Went.

In training there was a tradition of oil/water incompatibility between surgeons and medical types. It was reflexive, legendary, cultivated, part of the air we breathed. But also superficial: we said bad stuff about each other, yet -- no choice, of course -- interacted to the benefit of all. Like your embarrassing uncle: talk behind his back, but get along at family gatherings. In private practice, it's a different game: the animosities, it turns out, are real and impactful. It's not just surgeon - medical doc hostility: it's any doc on doc. Join the wrong clan, expect open hostility; damn the party-favor pretensions. It's real and serious, and deadly unpleasant. Pocketbook precludes pleasantry.

When I arrived in town, young and naive, ready to become everyone's favorite surgeon, I walked down the halls of the hospital (often lost!) smiling at everyone I saw, uttering expectant greetings. Didn't take long to notice: some doctors not only failed to return the salutation, they literally looked away. Not a word. Knowing nothing about me other than that I was the new guy at the Clinic, they had no hesitation: I was one of THEM, and deserved not the slightest notice. Well, OK. To some extent I understood, once I understood: the Clinic had just opened its first satellite office, and had recently signed an exclusive contract with a health insurer. The non-Clinic docs felt threatened, saw the Clinic as actively trying to put everyone else out of business (not only was that not true, but as time went on and the Clinic continued to grow with the community, the non-Clinic docs increased in number and thrived as well. Still, I didn't entirely blame them.) So I was branded. Some of those docs wouldn't have referred a patient to me if I started raising people from the dead. (Well, as time went on, some referred themselves when they needed surgery -- just never a patient.) In my infancy, I operated on the mother-in-law of the son of a prominent family doc whom I happened to use occasionally as an assistant -- an older guy who did lots of surgery himself, not particularly well, but knew his way around the other side of the table. During an operation he told me how much the woman had appreciated my care, and said he was impressed as well. He went on to explain that I surely must understand that, as a Clinic doc, he'd never send me a patient. He, and many others. Quality was not the overriding issue: it was where you parked your car.

The emergency room, which disrupted our lives and saddled us with cases we'd rather not take, at times we didn't like using time we didn't have, was the petrie dish in which, like familiar pathogens, much of the interpersonal enmity grew. As a reader of many fabulous ER blogs (this, this and this, to name but a few), I'm now ashamed to admit it: I wasn't always above dancing on the fine print of the staff bylaws to stay in bed at night. The on-call rules were arcane here, fluffy there, and made for many a midnight merengue. And when it involved a pirouette across political lines in the sand, grit got in the tutu.

"No-doc" call, meaning being designated to accept patients who showed up in the ER with no doctor of their own, was assigned among each of the specialties. There was no refusing a no-doc patient if you were the one on call, but it got trickier when the receiving doc called another specialist. Politics being what they were, generally the doctor who took the patient called people in his/her own political sphere to consult. And in fact the rules were that once a doctor accepted a patient, that patient was no longer "no doc." So other rules applied. I have no obligation (other than pragmatic ones) to agree to a consult request from a fellow (non-ER) physician. And after a few years of being shunned by those on the other side of the aisle, there were few things that annoyed me more than getting a call from some doctor who'd never refer to me, to be surgeon to his no-doc patient, when the only times it occurred were for a patient with a particularly unpleasant problem, and with no insurance. Otherwise, they'd have called their pal. So when it happened, I'd mostly say no. More often than not, I'd also say why. Until they'd be informed later that I was within my rights, the jilted physician would usually threaten me with some sort of medical staff censure. Such were the realities of politics, and of being tired at two a.m. It nearly got me into big trouble once, when a surgical competitor tried to screw me. In the political sense of the word.

Russian sailor shows up in the ER right after his ship docks in port. Story is he'd been sick for several weeks, with no way off the boat. He had a history of vomiting, abdominal pain, and bloating. No fever, no evidence of infection; vital signs OK, abdomen soft and not tender. The initial call from the ER doc went to the no-doc gastroenterologist, who'd ordered some lab work and a CAT scan, choosing not to see the guy until the results were in. The scan showed nothing specific except for fluid in the abdomen. "Call the no-doc surgeon," sez he. "Thanks, but no thanks," sez I. "Free fluid in the abdomen is a surgical emergency," sez the ER doc. "Not in a guy who's stable, got a soft belly, no signs of infection. What about ascites?" queries I. The ER doc, a new one whom I'd never met nor even heard of, quickly implies I'm derelict in my duties, in the most unpleasant terms. I reply that since Dr. GI accepted responsibility for the patient by ordering and evaluating tests, the man was now his patient, and I had no obligation to see him. The GI doc, of course, had never referred me a patient in his life.

What I actually said was I'd be happy to see the sailor as a consultant if after appropriate evaluation it was determined he had a surgical problem, and if, in the light of day, Dr. GI still wanted me to be his surgical consultant. I stated it did not sound like a surgical problem, and certainly not an emergency, at that time. There were a couple more calls. The ER doc, I realize, was stuck in the middle; on the other hand, he'd been exceedingly rude to me when I'd simply pointed out a medical and a political truisim. As far as he was concerned, I was criminally negligent, and said so rather gracelessly.

By rule, the only person who was actually derelict was the GI doc, who, having initially ordered tests, refused any further care. He managed, after I was temporarily out of the loop, to punt the case to the on-call family doc who generously admitted the man, and arranged for another GI consultant in the morning, who in turn asked me to see the man, which, of course, I did, and my exam confirmed my impression that he was not a "surgical" patient. He never became one, either, and shipped back to Russia a few days later.

As this post threatens to get too long, I'll skip ahead to when I'm sitting in the hospital medical director's office, having been called in to respond to a letter she'd received from the original GI doc, claiming I'd refused care of this patient and that it was a well-known pattern on my part. "Acts like he's the alpha-surgeon," was a nicely-turned phrase in the letter. I pointed out that the man's course proved I was right in concluding he was not a surgical patient, and that since Dr GI had de facto accepted the patient, I had no obligation even if he'd needed a surgeon; I then asked if she'd found any instances where I'd refused to come in to see a surgical patient, or if there were any prior complaints from ER folk about my responsiveness or my care. There were none. Quite, in fact, the opposite. And she agreed, after checking it out (like that ER doc, she was new in town), that I was right about the laws of succession. But, of course, the letter went into "my file."

I don't know what happened to that ER doc; I never saw him again. I sent a letter to all the GI docs in town (they'd recently actually worked out community call-sharing across political lines) saying that I would refuse ever to respond to a consult request from Dr. GI and they should either arrange their call schedule accordingly, or expect to need to refer surgical patients elsewhere if we were on call together. I even explained why: the letter. A certain amount of fecal matter on a few ventilation devices ensued, and as luck would have it, not long thereafter the two of us found ourselves together in an otherwise empty elevator. "That was a pretty strange episode," I said. "Especially the alpha surgeon part. We've never worked together. Where did you come up with that one?" Sheepishly, he offered, "Well, you're right. And you were right then. Actually, [surgical colleague of his, competitor of mine] was the one who said it was a well-known pattern. He encouraged me to write the letter. I wish I hadn't." "Me too," I said. "I guess I could give it a shot, forget about it, work together if it ever comes up." "Me too," he said.

And with that, hell froze over.

Hospital politics: the infamous memo. Part three

Where was I? Something about trauma centers....

So this Level Two thing was occurring at a time when the hospital was in a major funk. Nurses, as I said, were feeling lousy. Care was spotty, despite the presence of a bunch of the best nurses I'd known: they were overwhelmed with work, frustrated by lack of support. And despite this, because of the combination of sustained growth in our area, and the recent converting of many of the beds in the former competition to long-term care, the hospital was jam-packed much of the time. Having made commitments to using those beds across town for other purposes, and still running deficits, locked into an old building, the options for increasing bed space were few. And weren't happening. The ER (soon to become a high-level joint, evidently) was not rarely on "diversion," meaning the medics were told not to bring in new patients because there were no beds in which to put them. Elective operations were occasionally cancelled. Postoperative patients were sometimes kept in the recovery room for hours or overnight because there was no place to send them. Patients who might have otherwise gone to the ICU (intensive care unit) were kept there as well, for the same reasons. So among the least important issues for administration was attracting more patients. Patients, they had up the wazoo.

One more piece of the puzzle: trauma is, mostly, a money-loser for hospitals. Following a rule mentioned in a book I recommend, trauma happens to people who are asking for it (more of a county hospital rule, actually, but still...), meaning they have no insurance and governments don't pay well for them. Off the top of the head, it wouldn't seem like a desirable thing for a hospital already hurting financially. And this: whereas trauma is the lifeblood of surgical training, and something people in surgical training love, for most surgeons in busy practice (which describes all the town docs, clinic or not), it's not always welcome. If it happens in the night, it means you face the next day's schedule tired; if during the day, it throws already-busy schedules into chaos. Because unlike training (as described in a particular book), where the trauma service hangs around waiting to receive the next case, in practice you have a million other things to do. So the idea of doing more trauma, and having, on the days you were the designated trauma doc, basically to write off the whole day so as to be available by the rules of Level Two, was received -- let's see -- unenthusiastically. The anesthesia docs were similarly hypo-ebullient. Unlike any other issue including what time it was, on this everyone agreed, across all party lines.

Seeing danger down the road if its reputation didn't improve (several smaller hospitals line the periphery of the area, and they were salivating), the hospital embarked on an all-out effort to...... market itself. Not address care issues (OK, it's not as if they were totally unaware or making no attempts at all: but cost-cutting was the ne plus ultra, so not much was becoming apparent.) Marketing was where it was at.

I'm guessing the person who came up with it didn't last long in the advertising game, but the new slogan up with which the hospital came was "Nobody Cares More." Banners and posters appeared all over the hospital, and, of course, in TV and newspaper ads. I suppose you can guess how the hospital ones were defaced, in short order (not by me, I'd add: too mundane): Either the "More" was crossed out, or "Any" was added between Cares and More. Among the staff, it was a running joke. And it bears remembering, for later on.

I may have exaggerated when I said the move toward a Level Two Trauma Center united the medical staff. Fact is, since it didn't affect a lot of docs one way or the other, they didn't care. But those most affected -- surgeons of many specialties, and anesthesiologists -- were horrified at the prospect, and were of one voice in expressing their displeasure. And truly, it wasn't just about the work-load. It was very, very much also about concern over the hospital's ability to provide the resources to do it right, and the fact that the best around was within shouting distance. I wasn't the only one who'd had experiences like the one I described. But of this "one voice" it must be said that one vocal chord was paralyzed. That's because half of the docs in town, as mentioned earlier, were in bed with the hospital. So much so that if the hospital CEO had gotten the clap, they'd all have had to take penicillin. So much so that when they walked into the hospital, they were handed tubes of KY jelly. So -- and don't doubt that administration didn't know this very well -- when the hospital did something that the medical staff didn't like, half the staff kept their mouths shut. And the medical staff officers pretty much spent their time sending out memos telling us what plans the hospital had, with no input and no feedback. Puppet government? Puppet something: government seems a little generous.

So I was elected. The surgery department of the medical staff consisted of all surgeons in town, regardless of affiliation. Everyone knew I'd speak out and would say what was on all their minds, while allowing the rest to sit mute and enjoy deniability. "Sid, go talk to the CEO, and tell him why it's a bad idea," they all said, to man. And a couple of women. Give 'em hell, while we lube up. A meeting was scheduled with me, the CEO, and the hospital medical director. Armed with a well-prepared list of questions and issues that needed addressing, I spoke my piece, and was surprised by the candor of the response. "It's about market share, doctor. Our business plan is to be the referral center for the area, and being a level two trauma center will impress people, convince them we're the real deal." Or words to that effect. "Market share" is a verbatim quote. Providing service to the community was never mentioned, per se. What arguments did I have to counter "market share?"

The one thing they had done is to spiff up the ER a little: made it bigger, bought a couple of cool monitors. New paint. Being the second busiest ER in the whole state, it needed it, trauma center or no. What they hadn't done is make any effort to get the surgeons, et al, on board; no need, really. They held the cards, in terms of doling out staff privileges, and they had the other guys by the balls, and by whatever parts were available on the feminine side of the equation.

As I was talking with the rest of the surgical department and considering how to deal with the inevitable, what steps could be taken at least to ensure the best care possible, the hospital started running ads in the newspapers, when the paint was dry in the new ER. Here's an exact quote: "State of the art in every way, the ER is backed by an acute care hospital... We all hope that life-threatening traumas and illnesses never befall us or our loved ones. But if the unthinkable happens, isn't it nice to know that the very best help is available, right here at home." Let's be clear: "state of the art" does not mean Xray facilities five hallways away from the ER and which may or not be available, lack of onsite lab, or absence of clear protocols for handling given situations. The ad also listed the services available at the hospital. On the list was the term: Trauma Center. I suppose I can be self-righteous. I'm a surgeon, after all. But this really struck me as awful. To call the facility a trauma center, and to claim it was state of the art and that the very best help was available was, in my opinion, fraudulent. Premature at the very, VERY least. So I wrote a letter to the medical staff president and his executive committee. I included a copy of the offending ad, and said I thought it was time for the medical staff to step up and take a stand. Going ahead with a trauma center was a decision that seemed to have been made; but there was no reason we should be silent in the face of false advertising. I got a letter back. You shouldn't write letters like that, was the gist of it. My within-the-system wad was shot, I figured. I'd gone to meetings, I'd written letters, I'd talked formally and informally to administrators, physician officers. I felt the hospital was behaving as if all it had to do to be a trauma center was to hang up a sign in front of the ER. I'd lost the war.

So I distributed a memo to all of the doctors at the hospital. Put it in their mailboxes. From which it got pulled so fast hardly anyone saw it....