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Friday, March 28, 2014
Editor:
Paul Janson, MD, is to be congratulated for his thoughtful viewpoint, “Practicing Business Leaves You with Business.” (EMN 2014;36[3]:3; http://bit.ly/1eLk39p.)
 
Dr. Janson remains hopeful that physicians are still able to get ahead of the progressive commoditization of health care, but I am less optimistic. Indeed, my sense is that physicians have largely abrogated their fiduciary responsibility to do what is best for their patients rather than to do what is best for themselves and for their taskmasters — hospital administrators.
 
Lifestyle choices that include maintaining an ideal body weight, not smoking, regular daily exercise, avoiding intoxicating substances in excess, childhood immunization, and prenatal care will go the farthest toward improving public health. Barring these, emergency physicians are faced with the realities of the bottom of the societal birdcage. EPs are the stewards of a vast resource of medical care and technologies, but these practitioners’ task is Sisyphean when faced with onerous oversight, unfunded mandates like electronic health records and computer physician order entry, Orwellian tort law, and scientifically unsupportable “clinical benchmarks.”
 
The unchecked proliferation of hospital administrators and CFOs and their clout (and their handsome salaries) is in inverse proportion to the autonomy, the respectability, and, indeed, the preeminence of physicians in health care.
Judging from America’s poor performance in public health metrics despite throwing an unsustainable percentage of its GDP at the challenge, our predicament is deeply concerning if not alarming. Regardless, congratulations to Dr. Janson, whose 40 years of service is part of the solution.
 
David M. Lemonick, MD
Pittsburgh

Wednesday, December 11, 2013
Editor:
I heartily agree with the observation that conflicts of interest are beginning to become all too prominent in the debate over thrombolytic therapy for stroke. (“Conflicts of Interest on Guidelines Ramp Up tPA Controversy,” EMN 2013;35[10]:1; http://bit.ly/1hAdtVi.) The arguments cited are compelling and well stated, needing no further addition here, but I fear the issue goes deeper than is appreciated.
 
Normally, the conflict of interest is dealt with in the present tense, what interests exist now, without consideration of future potential relationships, but an individual who advocates practices that are valuable to corporations will be more likely to be offered advancement or potential financial benefits in the future.
 
This does not suggest any dishonesty or conspiracy; it is simply inherent in the system as it exists now. The tremendous power, financial and political, that is wielded by the medical industries makes this outcome inevitable. In the strongly market-oriented economic system that dominates the United States, we should not be surprised that health care is also dominated by market considerations. It would be foolish to expect the manufacturer of computer software to promote any solution that does not utilize their software, and so a pharmaceutical corporation is naturally going to favor those who advocate the treatment that that corporation provides and attempt to minimize the influence of those who oppose that treatment.
 
The spider web in which the health care system and our own health is ensnared is so pervasive that any movement causes the whole to move — and to be restrained by that web as well. We should not be surprised that conflicts of interests seem to arise so frequently in an issue with so much financial risk. It is not surprising that they are ordinarily so well concealed either. Alas, the solution might require far greater adjustments than simply “disclosing” who is currently being paid by whom. Investigators are very capable of seeing where the future is going.
 
Paul Janson, MD
Georgetown, MA

Tuesday, August 27, 2013

Editor:
So there comes Edwin Leap again, into my home with my dog and my filtered light and my feet up and my cup of hot liquid tranquility reminding me that I am neither beast nor fowl, but a creature formed of the emergency departments I have known. Like Charity New Orleans, with 273,000 patient visits each year to the first floor, which includes the ortho clinic, the peds ER, psych, the accident room, and the MER (medical emergencies). (“Stop Sucking It Up,” EMN 2013;35[8]:11; http://bit.ly/16wYsiD.)

A gunshot to the head every five minutes on a Friday night. I remember that shift. Oh, there were grazes, and there were juniors in high school screwing around with their guns, but there were machine guns, too. I remember a man busted for drugs who had just killed the husband of a wounded woman on the gurney next to him. He yelled, "Get her! She has a gun!" Sure enough, she was pulling a machine gun out of her clothing, and was about to spray her husband’s killer with bullets. We pushed the gurney hard, and she fell to the floor, and then she had blunt as well as penetrating trauma. Plus she was head injured, but we had done it to save the scene.

And there was the time a demented HIV patient grabbed the blood gas syringe and tried to stab the phlebotomist. We all yelled, "Shoot him!" to the ever-present police, but they wouldn't. So we threw a mattress on him.

I have told a nun and a 9-year-old they were pregnant, and watched a father tear up an ER in Slidell with an e-cylinder when he was told his wife had rolled over on their child. The 1-month-old, who was being lined and tubed, then coded, and the father had to be subdued after he ripped the lines and ETT out of the infant’s mouth.

I once had to board a helicopter for Ochsner Health Center coding a kid, though I knew he would die. And there was the time I was radioed to come look at a head on the bumper of the car that had hit a person on the freeway. And the time that I closed St. Claude, an ER in the Lower Ninth Ward, for an hour so I could go in the ambulance to Charity with a woman whose infant’s feet were sticking out of her vagina. I almost lost my job for that.

There was also the day four cops were killed, and a fifth came in shot up. I was on the ramp, and received him to a gurney from the back of a rig, but he died in Room 4. The cops went on the rampage, and we had trauma from hell all night long.

Another time, I saw a woman with a dog in triage, and the dog's penis had swelled up inside her. One time I saw a domestic dispute that ended with a man putting a fork in his wife's breast and she a fork in his testicle. Then there’s the cocaine MI guy who spit in my mouth and … and … and….

I’ve been an ED doc for 17 years, mostly nights, because that was where the action was the most interesting. I do have post-traumatic visions. I have seen genital warts that looked like cauliflower. One man said something is "down there," and he had a spaghetti squash with sprouting green foliage. I have seen 30 feet of piano wire threaded up the penis into the bladder, and a variety things pushed up toward the prostate, including a vibrator (still on), a frozen trout, a jar of mayonnaise, a sausage, and a gerbil taped up alive.

I was in emergency medicine residency at Charity Hospital from 1993 to 1997, which prepared me for four years at St. Claude. The enormity of the experience was tamped down when I moved to Portland, OR, where the work was less surgical, more medical. Still, horror happened. Hearts were broken. Love was lost. There was internecine warfare between the ED docs under siege and the administrators who pushed us. Trauma, for sure. Sort of like the time in Oakland General when I did a full mouth extraction of all of the teeth of a homeless man. I feel as if I, too, have been on the floor of a hall and have had teeth extracted, but those teeth were not rotten; they were decent and strong. Still, they were pulled from me like some white dream wafting away, as if it were easy to lose that innocence. Till the sting is felt. The loss known like a toothache lingers.

But what I feel is not sadness or regret. Rather, it is a cold and a broken hallelujah. Leonard Cohen and sometimes Bob Dylan have always played backup in my brain as the visions came in. And I have kept a journal, and as Dr. Leap mentioned, writing helps. Every day I pick a case that made the cut to posterity and have written about it. I have boxes of journals that I never read. I write to rid myself of the need to remember. And I tell stories; my parents love the stuff. And my husband. He is a doctor, too, and he enjoys the advanced pathology, the strangeness, the old, the young, the worst of every subspecialty: emergency medicine.

I do not avert my eyes. There will be years to be dead. They are not now. Now I fully engage in every story, and I ask for details. And I get them. I call it "venue.” We have venue. I do not do a victory march. No one wins in my estimation. We meditatively consider options; we do not argue, judge, or deny. We pass through, and the thoughts pass through, like a meditation.

I would agree with Dr. Leap; perhaps breaks are good. I feel I have been on break for three years since I cut back to just two 12-hour shifts per week and urgent care more than emergent. When it does hit the fan, I can hang without second-guessing too long or hard after. Sleep does not evade me.

Perhaps we turn to friends for fun and affection; perhaps art, music, or exercise resets the energy meter. I know that empathy erodes with stress and sleeplessness; that is known to happen to everyone. What makes a good ED doc, I think, is the same thing that would make you good at whatever else you do: you show up, fully present. When away, you are away, far away, running in Forest Park with the dog listening to African drums.

The sound of a siren is like the sound of a morning alarm clock, and I throw a PVC every time. But it is in its little place, and a tower of song surrounds it, belting out the blues. I hear that drum louder than I feel the worry of what is going wrong.

It has been a good life. The best. Collaborative, educational. I could quit. I don't. And I don't add to the water in my vision with tears over what I've seen. There is enough water in Oregon's skies.

Plus if it all falls apart with the Republicans hijacking the government and the markets failing, I know how to live out of a shopping cart. I asked a guy about that once.

Christine Bugas, DO
Portland, OR


Wednesday, June 19, 2013
‘tPA is What We Have’
Editor:
The American College of Emergency Physicians (ACEP) and American Academy of Neurology’s (AAN) joint policy on using intravenous tPA for managing acute ischemic stroke in the emergency department was developed after an exhaustive review of the medical literature and involved extensive evaluation by emergency physicians, the Society for Academic Emergency Medicine, the Emergency Nurses Association, the American College of Physicians, the Neurocritical Care Society, and the American Stroke Association. The sole funding sources for the development and publication of this clinical policy were ACEP and AAN. (“The ‘Biggest, Baddest’ Controvery in EM,” EMN 2013;35[4]:1; http://bit.ly/12F9m4r.)
 
The expansion of the treatment time window to 4.5 hours is in accord with the European Cooperative Acute Stroke Study. The American Academy of Emergency Medicine’s 2012 position statement on tPA, contrary to what is stated in your article, supports the ACEP and AAN clinical policy, and offers no caveat about tPA not being a standard of care.
 
Nothing we do in emergency medicine comes without risk, and many things we don’t do carry substantial risk as well. The world of emergency medicine is still divided over using tPA to treat acute ischemic stroke, but the stroke patient community is not: 88 percent of lawsuits involving tPA ischemic stroke therapy were filed over failure to treat with tPA. (Ann Emerg Med 2008;52[2]:160.) Less than two-thirds of plaintiffs prevailed, but of those who did, 83 percent involved failure to treat.
 
In the absence of something better, we work with what we have to reduce death and disability from stroke, and tPA is what we have. Nobody is more invested in improving treatment options for this devastating injury than emergency physicians and neurologists. ACEP worked with the AAN on revising the clinical policy at the urging of our members. It reflects more than 10 years of work by emergency physicians who are extraordinarily sensitive to the potential serious effects of any physician treatment choices as well as the valid concerns of physicians who might administer it.
 
The policy is not compulsory; it is merely a recommendation and leaves the final treatment decision to the physician. It also spells out that the hospital must have a system in place for treating stroke patients or the ability to transfer these patients to facilities that can before administering tPA.
 
Andy Sama, MD
President, ACEP

Editor’s Note: Dr. Sama’s letter notes that the American Academy of Emergency Medicine’s position statement on tPA supports the ACEP and AAN clinical policy and offers no caveat about tPA not being a standard of care. The following statement, however, verbatim from AAEM’s website, notes: “It is the position of the American Academy of Emergency Medicine that objective evidence regarding the efficacy, safety, and applicability of tPA for acute ischemic stroke is insufficient to warrant its classification as standard of care. Until additional evidence clarifies such controversies, physicians are advised to use their discretion when considering its use. Given the cited absence of definitive evidence, AAEM believes it is inappropriate to claim that either use or non-use of intravenous thrombolytic therapy constitutes a standard of care issue in the treatment of stroke.” (Read AAEM's policy statement at http://bit.ly/Wlwm9N.)
 
Robert McNamara, MD, a past president of AAEM and a professor and the chair of emergency medicine at the Temple University School of Medicine, said the confusion may have resulted from an email issued by the Centers for Disease Control and Prevention stating that the academy endorsed tPA for stroke. The CDC was referring to a Clinical Practice Advisory issued by AAEM and not a position statement. AAEM set the record straight in a letter to the CDC requesting a correction. (Read the letter at http://bit.ly/150ejbX.)
 
AAEM stated that tPA is one treatment option for stroke when given in academic medical centers and prepared stroke centers, and called for EPs to have the resources, such as a stroke team, to optimally care for suspected stroke patients. The letter also said hospitals should formulate a plan for timely care of patient with suspected acute stroke. The full AAEM Clinical Practice Advisory is available at http://bit.ly/AAEMtPApolicy.

Thursday, May 30, 2013
Editor:
Because of the greed of physician consultants and the companies that employ them and the cowardice of hospital administrators, an EP who wants to continue putting food on the table can no more ignore Press Ganey than he can ignore EMTALA or ACLS. (“Forget Press Ganey: Why You Should Embrace Patient Satisfaction,” EMN 2013;35[3]:1; http://bit.ly/ZAfD4s.)
 
Patient satisfaction scores are the third rail of conversation in most of the EDs in the country. Honest, bright, hard-working EPs are being punished economically and professionally because of the lazy and inaccurate way that their work is being evaluated.
 
Let’s dispel a myth right here. EPs do not mind being honestly graded and evaluated. High school, college, med school, residency, fellowship — we have spent our entire lives being tested and graded. Most of us do not mind the challenge of a test and the judgment that comes from an honest grade. The grades that Press Ganey produces do not reflect reality. The number of responses that constitute my Press Ganey score for the past six months averages one to three percent of the total number of patients that I treat. In no month has my average been four percent or higher. Ninety-six to 99 percent of my work is not being “graded.” How is that a fair or honest appraisal of the quality of my work or my skill as a physician? If I were to grade the accuracy of your article, it would probably be a D+ or maybe a C- (you did include a paragraph acknowledging the inherent inaccuracy in the Press Ganey physician scores).
 
There are no opponents to patient satisfaction. Every emergency medicine provider that I have known over 20 years of practice cares deeply that patients feel safe, comfortable, and satisfied. What we object to is the impugnation of our work, the unfair and incorrect way that satisfaction is measured, and the patronizing and condescending inference that we don’t care about our patients.
 
He also uses the terms “patient satisfaction” and “patient-physician interaction” interchangeably. This is a mistake. He also conflagrates the terms “patient satisfaction scores” with “patient satisfaction.” I heard a politician recently discussing his plan to lower health care costs by “improving quality.” Satisfaction, interaction, quality — these are all very protean terms, depending on who is using them. Evidence is accumulating that patient satisfaction and satisfaction scores and quality are difficult to quantify, and are not interchangeable; one does not necessarily imply the other. We need to acknowledge and repeat over and over again that patient satisfaction scores, especially ones that only record one to three percent of the work performed, do not reflect actual patient satisfaction or quality.
 
If one really wants to know what is driving this patient satisfaction hysteria, just follow the money. Who is getting rich pushing the patient satisfaction Kool-Aid? Well, Press Ganey is an easy target. According to Forbes, the company was founded in 1985 and was considered a niche service until 2002 when the Centers for Medicaid and Medicare Services began a national program to survey patients and require public reporting of the results. That empowered Press Ganey, which was taken private in 2003 by American Securities for a reported $100 million. Four years later, it was flipped to another private equity outfit, Vestar, for a reported $673 million. Since then, revenue at Press Ganey has grown at high single digits; it earned $82 million (EBITDA) on $217 million in sales in 2011.
 
There are competitor survey companies, to be sure, but Press Ganey is the big gorilla in this cottage industry that has spawned another detestable tumor — the consultant hired by hospital administrators to bully and berate physicians and nurses into scripted and hollow charades “guaranteed” to improve satisfaction scores. Prominent physicians and ACEP board members have traded their political and academic positions to make a quick buck as patient satisfaction consultants. These men and women should be ashamed of themselves and the naked betrayal of their colleagues.
 
The good news is that at some point this will all go away. All this patient satisfaction hysteria will someday be just a bad memory like polio or smallpox. I say this for two reasons; first, it cannot be sustained simply from a financial perspective. How much money is being spent on surveys and consultants and training, not to mention the expense of unnecessary testing and prescribing? A recent online poll found that an astounding 59 percent of respondent physicians admitted increasing the number of tests that they perform just because of patient satisfaction scores. This says nothing of the number of unnecessary prescriptions, procedures, or admissions performed. The system will collapse under the sheer weight of the cost of patient satisfaction. The second reason this will all go away is that it is a house built on sand. Everyone knows that the patient satisfaction surveys and responses are a joke. How long can the scam be kept up before someone (CMS or some other administrator or politician) that controls the money calls it out?
 
EPs are exhausted. The patient satisfaction portion of the monthly staff meeting has become the time for a bathroom break, much to the panic, horror, and chagrin of the administrators. Every honest EP has the moral responsibility to resist the patient satisfaction score hysteria for the sake and safety of our patients and the future of this great and noble profession.
 
Gerald F. O’Malley, DO
Philadelphia