I've been feeling censored and haven't wanted to write lately. When the editor of EMN told me I had a strong, unique voice and asked me to write a column, it was one of the most empowering opportunities of my life. The pure joy of expressing my inner truths about my life in emergency medicine and knowing that they are resonating with people has made me as passionate about writing as I am about doctoring. I've learned through opening up about my experiences with depression, gender stereotypes, motherhood, and dating that no matter how afraid I may be to say something, somebody relates to it and appreciates it. And I absolutely love it. Well, I loved it until admin discovered my column.
For a while, I kicked my laptop out of my bed, and it sat lonely and unloved in my office. Now I am too worried about how I could get in trouble by writing honestly about what I'm thinking. My hesitation highlights a dynamic that's prevalent in the field of medicine: the fear of being punished for speaking up.
Fear is for good reason, especially in EM, because many of us have signed contracts with staffing companies that accord us no due process rights. The universal guarantee of due process in the Fifth Amendment to the U.S. Constitution says, “No person shall...be deprived of life, liberty, or property, without due process of law.” Due process means that clinicians will not lose their medical staff privileges without a fair hearing. In the absence of due process, the threat of being fired on a whim without the right of a hearing makes it very scary for physicians to advocate for their patients or themselves.
A quick Internet search will make even the most outspoken EPs want to hold their tongues after seeing news stories about physicians getting fired for speaking out. Wanda Espinoza-Cruz, DO, talked to the hospital CEO about patient safety and low staffing levels after a stroke patient sat in her waiting room for so long that he was outside the window for intervention by the time he was seen. (Tampa Bay Times. Feb. 20, 2015; http://bit.ly/2n4ULU1.) The CEO called the corporate staffing group, and she was fired the very next day despite a previously unblemished personnel file. No hearing. No explanation. No due process.
Cloyd Gatrell, MD, raised concerns about patient safety related to his hospital allegedly not hiring enough nurses, which led to ED waits of up to eight hours. He was fired. (ASQ. Jan. 17, 2014; http://bit.ly/2n4MgIF.)
It happens in Canada too. Jon Witt, MD, wrote in a letter on behalf of his colleagues about their collective concern that understaffing was killing patients. The letter was leaked to the press, and he was fired. (The Globe and Mail. March 18, 2014; https://tgam.ca/2n4Tixf.)
What these dismissals are saying is, “If you've got any concerns at all as a medical professional, you better not say anything about it or your job could be in jeopardy.”
So, yes, now I am nervous about every word I write. I work in a great ED and have never had a desire to leave. I'm not trying to be a whistleblower. I'm just an articulate person with the passion to pour my heart into a monthly column and candidly tell my story. I'm no Jim Roberts, MD, the clinical procedure guru. I'm no Scott Weingart, MD, emergency medicine's resuscitation celeb. Mine is the voice of a not-famous, nonresearcher, everyday community clinician. We all have similar frustrations and have similar conversations among ourselves in the doctors' lounge. Just like Fat Man in Samuel Shem's The House of God says, “I spell out what every other doc feels, but most wash down and let eat away at their guts.”
Dismissals as Gag Orders
Reporting what every other doc feels shouldn't take bravery, but unfortunately, it does because no matter how good we are at our jobs, the threat of termination for something we say is always hanging over our heads. Society expects physicians to advocate for the best care for our patients, even when we must advocate against the interests of the hospital. Yet we are afraid of upsetting hospital leadership and consequently losing our ability to support our families.
We need to change this dynamic. Dismissals are gag orders. Just like I love my sons but speak up when they veer off track, EPs should be able to speak up about problems in a specialty we love. We could all take better care of our patients if certain system-wide issues improved. If we can't speak up about systemic issues because we are afraid for our jobs, how do we make health care better?
Not saying what we have to say will gnaw at us. For some of us, it will fester into depression and suicide. We sacrifice so much for this career that to be told to be just a worker bee does not lead to satisfaction in the long run. We didn't do all this training to fall in line and be a drone. “[Forcing] EPs to practice under their [contract management groups'] economically driven guidelines or fear termination ... is a patient safety and quality of care issue,” wrote Kevin Rodgers, MD, the president of the American Academy of Emergency Medicine, in his message about due process in the May/June 2016 edition of Common Sense. (http://bit.ly/2n53WDY.) “[E]xploitation and abuse of EM physicians in the workplace is a significant contributor to physician burnout.”
I encourage every EP to read and sign AAEM's petition supporting our due process rights. (http://www.aaem.org/dueprocess/petition.) Non-doctors are running health care, and we as a group are implying consent through our complacency. We listen to admin talk to us about avoiding downcoding, increasing patient satisfaction scores, and keeping the wait time metrics down, so they should reciprocate and listen to us. We're the ones who are “moving the meat,” who are working single-coverage night shifts, and who are going to be there when your family comes in. Hospitals should value the opinions of those of us actually in the trenches instead of looking at us as a PR liability.
“But what if a patient found your column?” Then that patient would see that I'm someone who cares enough to speak up and make a difference and would hopefully realize that I'll advocate for them in the same way. Instead of scrutinizing the “appropriateness” of my writing, I would hope patients and admin would respect and listen to someone with enough authenticity and courage to put her truths out there.
At the end of the day, the things we cannot speak about are the things that burden us most. Mine is just one doctor's voice, but all of us share my disillusionment. Singing out my truths alone amid the cacophony, I am easily mutable. But silencing one physician who speaks up isn't going to make our concerns go away. Yes, individuals get fired, but large groups get heard. Our voices in unison will bellow a powerful melody. Real change can take place if we doctors take a stand, band together, and belt out, “ENOUGH!”