Worse, I see it in hospitals now. I hear so many nurses say, “I can't do that. I'll get in trouble.” I remember the time I asked a secretary to help me send a photo of a fracture to an orthopedic surgeon (with the patient's consent, mind you). “That's a HIPAA violation, and I'm not losing my job to do it!” OK....
There have been times I've said, “Please print the patient's labs so they can take it to their doctor tomorrow.” The response? “No way! That's against the rules! I'll get in trouble!” Seems rational. The patient asks for his own labs and takes them to his doctor. It can only be for nefarious purposes ... like health!
Sometimes it's even sillier. Me: “Patient in bed two needs an ECG!” Nurse: “You have to put in the order first, or I'll get in trouble.” In fact, this theme emerges again and again when I ask for things like dressings, splints, labs, or anything else on a busy shift. I've expressed my frustration about physician order entry before, and I know it's a losing battle. When there is one of me, three or four of them, and 10 patients or more, it's difficult to enter every order contemporaneously. But I know, “you'll get in trouble.”
I remember being told by a well-meaning (and obviously threatened) nurse, “If I put on a dressing without an order, it's like practicing medicine without a license and I can lose my nursing license.” That makes sense!
I overheard a nursing meeting not long ago, and it seemed that the nurse manager (obviously echoing her higher-ups) was more concerned with making sure the nurses didn't do wrong things than with anything touching on the actual care of human beings.
I suppose it's no surprise. “When all you have is a hammer,” the saying goes, “all the world's a nail.” Now that we have given all of medicine to the control of persons trained in management, finance, and corporatism, that's the thing they have to offer. Rules, regulations, and, ultimately, threats.
Of course, getting in trouble applies to physicians as well. It just takes a different form. Didn't get that door-to-needle, door-to-door, door-to-cath lab, door-to-CT time? We'll take your money. Didn't get the patient admitted in the committee-approved time? We'll take your money.
Never mind that seeing patients in a timely manner is rendered nigh impossible by the overwhelming and growing volumes of patients coupled with the non-stop documentation of said patients for billing purposes. Keep shooting for those times! Times are easier metrics to measure. Times are easily reported to insurers and the government. Times, charts, rules followed, rules violated. The vital signs of corporate medicine in America today. (And don't give me that “it would all be better with the government in charge.” Two letters reveal that lie: VA.)
No, we're an industry constantly in trouble. But not for any good reason. We give good care as much as we are logistically able. We still save lives, comfort the wounded and dying, arrange the follow-up, care for the addicted and the depressed. We still do more with less with every passing year.
Fear and Threats
Odds are, we won't stop getting in trouble. Waving the stick is the only management technique some people know. Still, it saddens me. I'm sad for all of the powerless. The nurses and techs and clerks and all the rest who are treated as replaceable commodities by administrators who are themselves (in fact) also replaceable. I hate to see nurses — compassionate, brilliant, and competent — walk on egg shells in endless fear, not of medical error but administrative sin. Their jobs are hard enough already without that tyranny leveled by people who should appreciate rather than harass them.
It saddens me for young physicians who don't remember when being a physician was a thing of power and influence in a hospital. They, endlessly threatened and unable to escape thanks to student loans, are indentured for life, short of a faked death certificate.
And it saddens me for the sick and dying. We cannot do our best when our motives are driven by fear more than skill and compassion.
The truth is, however, threats only go so far. Once people have been threatened enough, there's no telling how they'll respond.
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