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Second Opinion: An Update from the Republic of Emergistan

Leap, Edwin MD

doi: 10.1097/01.EEM.0000428928.88405.d3
Second Opinion

Dr. Leap is a member of Blue Ridge Emergency Physicians, an emergency physician at Oconee Memorial Hospital in Seneca, SC, a member of the board of directors for the South Carolina College of Emergency Physicians, and an op-ed columnist for the Greenville News. He is also the author of three books, Working Knights, Cats Don't Hike, and The Practice Test, and of his own blog. (See FastLinks.)





Life is a journey full of course corrections. At every point, if we are wise, we reassess and reevaluate the things we believe, the opinions we hold. We also do this in the science of medicine, of course. Knowledge advances, treatments change, outcomes change. To be static is to die, it seems.

And so, I come before you with my own course corrections, my own emerging insights. As a writer and a physician, how can I stay the same?

I have railed against the pain scale for years. And yet, I see now that unnecessary suffering will be the rule without it. Pain is ubiquitous, and while we cannot always heal, we can always ease. Who are we to say who does and does not feel pain, and to what degree? This is the best we'll have until the painometer is available.

Along the same lines, addiction is very real, and it isn't my job to decide who is and isn't addicted, is it? If I suggest that a patient is not really suffering when he says he is, I only call him a liar. And what gives me the right to make such a value judgment about another human being? The best I can do is believe and treat the individual in pain.

What else, you ask? What other flashes of insight have finally illuminated the darkness? Surprisingly, I see the utility of patient satisfaction scores. To use anything other than the patient's perception is to impose our own “scientific” paradigm onto the people we treat. Only when patients themselves can say whether we succeeded in meeting their needs (and desires) can we be certain we have done the right thing, in the right way, for those who trust us with their health.



There's more. I was wrong to be too harsh toward electronic medical records. The government, in its wisdom (which I must confess I now see in a new light), did the right thing by imposing EMR rules. EMR allows us to document in far greater detail the intricacies and nuances of our patient encounters, and provides insurers and government agencies vastly more information with which to, quite reasonably, assess payment and quality. And let's face it, by doing so, the information technology economy has been well and duly stimulated. So down with the pen and paper! Up with the screen!

And I owe a special apology to administrators, those tireless folks whose 9-5 jobs are jam-packed with efforts to make my care more effective and efficient. I've been pretty tough on the gals and guys in business suits who labor to keep hospitals afloat. Sometimes, quite frankly, doctors need to be smacked around by MBAs. What do most of us know about the business of medicine anyway? Or, in the big picture, about how to make medicine more efficient? Administrators are big-picture folks. I need to cut them a break.

I could go on. I'm a harsh, narrow-minded, judgmental guy sometimes. I need to remember that. And I ask you, my reader, to remember this:

April Fool's! Look, if you know me, you'd know that I'd hold those opinions only if someone were threatening my family or I had suffered a stroke. So let me reaffirm and reassure you all.

The pain scale is stupid. It has caused far more harm than good. This is the reason that my motto for the Republic of Emergistan is “Semper a Decem.” Always a 10. Addiction is everywhere, and every ne'er-do-well in America goes to his local ED to troll for drugs, and each of them has unverifiable pain that's 10/10. If we could subtract the amount of time and money we spend tracking down fake complaints, EDs would be far cheaper and efficient.

EMR is KILLING medicine. Killing it, I say, especially in the ED where we are held to ridiculous standards. “See lots of patients, see them quickly, treat them well, make them feel special, make all of your quality indicators for time (time until seen by physician, time until cath lab, time until CT). But do all of it while constantly charting real-time and while producing a chart that is so dense and complex that the real complaint is often impossible to find.” As many have said, the physician is the highest paid data entry clerk in the country today! Boo, EMR! Until someone makes it simple and deletes 80 percent of the fields, I'd rather check off boxes on paper and then dictate the complex encounters.

As for administrators, I know that managing a hospital is tough. I get it. I also understand that medical economics is complex. But given that the hospital exists for the purpose of caring for the patient and given that the patient is cared for by physicians and nurses, etc., the good administrator should view his job as ancillary and supportive of the medical staff.

When administrators become a force all their own and when they consistently ignore and denigrate the views of caregivers, when they make more work instead of less for clinicians, when they fail to take the side of their staff in disputes, then they have simply become another drag on an already crashing system.

But I'm not done! Medicine is in a tailspin. We face more patients, more entitlement, more rules and regulations, more fake diseases, more medicalization of every life crisis, more government intervention, more things we can go to jail for doing or not doing. And we face less accountability of patients, administrators, politicians and policy makers, less funding, less freedom, fewer drugs and therapies, and fewer physicians!

Don't worry, friends. I'll keep beating the same drum as always. Because whatever month it is, I believe in you. And I believe in our mission. It's time people started listening to what we say about emergency medicine because we are anything but fools when it comes to doing the right thing in the right way.

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