Most modern Americans are familiar with the classic political novel Atlas Shrugged. Love it or hate it, the novel had a great impact on political thinking in the West. One of the fundamental questions author Ayn Rand asks is, what if the producers and innovators of society simply stopped trying? What if they became tired of contributing and being abused, demonized and taxed for their efforts, and simply withdrew their contributions?
Atlas is straining in medicine as the weight of contemporary health care continues to fall on emergency departments and as increasing numbers of physicians in other fields retire or escape from call duties. I don't necessarily say this by way of critique. I understand the perspective of those who have, quite reasonably, made tactical withdrawals from the losing battle.
We have fewer available specialists. Drug shortages are rampant. Psychiatric beds are rare as state budgets plummet. Committees and professional societies heap volumes and volumes of new rules on the practitioners of medicine, as if it weren't already difficult enough. And yet, at the end of the day, the answer is typically: go to the emergency department; they'll sort it all out. And we are full, overwhelmed, understaffed, underfunded, and overextended.
What if we took a cue from Atlas Shrugged? What if, in one grand, unified effort, emergency physicians decided to stop doing their work, if only for a day? Or what if we all found another permanent way to earn our incomes? What if we said “no” to more satisfaction surveys, endless psych holds, innumerable Medicare regulations, and pointless Joint Commission visits? If we refused to be fined for not washing our hands every five seconds, if we said “15 minutes to a doctor” is ridiculous, if we explained that blood cultures didn't matter for most patients and that we were finished giving thrombolytics for stroke when we felt it was the wrong thing to do? What if rule-makers and fine-givers and policywriters were stuck, for just one day, sorting through the madness that was born of unfunded mandates and unintended consequences? What if we just said NO?
Like that game we all play called “what if I won the lottery,” it's all academic. That is, an Atlas Shrugged moment would be unlikely. We aren't organized enough, for one thing. For another, we couldn't replace our incomes (and therefore pay our debts and bills) that easily ... or that quickly. We also generally dislike change, and we have a wonderful, awful habit of following orders and doing “the right thing.” It's what got us into medicine, but it's also what will keep us there far beyond reasonable levels of endurance.
Another reason emerges, however. We feel a sense of duty, a sense of obligation, to the patients who come through our doors. No matter how bizarre or difficult the work, we press on and do it. We station ourselves at all hours of the day and night between patients and death, between patients and disability (no matter how much some of them want it!), and between patients and suffering.
I recently realized the dedication of my partners and staff as I watched a drunk “patron” wield his walking stick at our security officer. A deputy politely said, “Excuse me,” as he pushed his way past everyone and fired a TASER into the stick-wielding gentleman. The drunk man dropped fast, and was hauled away to the law enforcement center in handcuffs.
I realized it a few months ago when an angry psychiatric patient, who had a “sitter” while he awaited placement, picked up the sitter's laptop and smashed it through the clear plastic window around the nurses' station.
My stories are mild compared with some of yours. You face violent gang members while I more often face obnoxious drunk Southerners. Many of you face illegals with drug-resistant TB while I am a scalpel-wielding warrior facing MRSA abscesses by the bucket. I sort through rattlesnake venom and Xanax overdoses while some of you face designer drugs of no known origin, composition, or effect.
Of course, we do it all professionally. We do it the best way we know how, with fewer and fewer resources. We do it with falling reimbursement and increasing regulatory burdens. We do it day and night, holidays and weekends. It lacks the glamour and gloss of sexy doctors on television shows. It falls short of the moral clarity actors and politicians seem to bring to modern medicine. It is murky and difficult, even on the best days.
Our “office” is the place of chaos. An administrator once told me, on a day of terrible crowding and dangerous volume, that he couldn't move patients upstairs to the hallway. “Dr. Leap,” he explained, “when people leave the ER, they expect to go to a better place.” I walked away, unable to speak.
What workplaces are like this, outside of law enforcement, EMS, or the military? And who would face such things with regularity even as their reimbursement was cut, their threat of lawsuit ever-present, and their every move regulated and watched as if living on parole?
Atlas, at least in medicine, isn't likely to shrug off his duty. Oddly, we love what we do even on the days we despise it. But that's a pretty frightening “what if.” All of the senators and congressmen could walk out tomorrow, and we'd experience little more than a sudden burst in economic activity. Most of the attorneys could do the same, and our litigation would remain gridlocked, like much of it already is. But some things matter every day of the year. Gas has to be refined and pumped. Cars, buses, and airplanes have to move people and material. Electricity, water, and food have to be available. Disease and injury need to be treated. Even Atlas needs some relief, needs to make a living, and needs to pay his bills. For Atlas, at least in our profession, the honor and glory of carrying everything is wearing off. And yet, Atlas endures.
What am I trying to say? Well, it's Thanksgiving this month, so here's a reason for thanks. America should be thankful that emergency departments are open, and that they are staffed around the clock by well educated, dedicated professionals who don't shirk their duties.
They should be thankful that they so far haven't shrugged off the enormous weight that rests upon their broad shoulders daily. America should pray that they never do. If Atlas shrugs off health care, it will be a dark day indeed.
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