Healing Words: Social MacGyvering Erodes EP Wellness : Emergency Medicine News

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Healing Words

Healing Words

Social MacGyvering Erodes EP Wellness

Mosley, Mark MD, MPH

doi: 10.1097/01.EEM.0000898252.54855.1d
    wellness, social determinants

    Could Lisa Rosenbaum, MD, have had emergency physicians in mind when she wrote, if you want to fix the health care system, enable doctors to do what they set out to do?(N Engl J Med. 2022;386[19]:1850; https://bit.ly/3Rd0ekN.) After all, we are uniquely adept in crisis situations to find workarounds for what we set out to do.

    So common is this scenario in emergency medicine that MacGyver has become a patron saint of the ED. To MacGyver through a crisis situation becomes a distinction of keen awareness, particular skill, intuitive creativity, dogged persistence, and a fair amount of luck (and, of course, available nursing). This is honorable, even invigorating, for the immediate emergent medical crisis at the bedside.

    We have learned that the environment of the disease is more predictive of disability than the disease itself. We acknowledge that social determinants of disease and the political and social structures that reinforce them are at the heart of health, sometimes in spite of what we do. Nothing could illustrate this more clearly than the pandemic.

    But it should not be up to us to MacGyver social determinants—all of the prescriptions, rides, safety, housing, clothing, gun control, and timely follow-up, all without breaking the law. The commitment to a lifetime of bedside medical skill deserves a medal of professional heroism, but this becomes an albatross hung around physicians' necks when they are made to perform this duty curbside. Emergency physicians must learn to set clear boundaries between the bedside for which they are trained and the curbside for which they are not.

    Not Really a Fix

    The most recent social misappropriation of emergency physician duties is pharmaceutical pricing and e-prescribing from the ED, especially after-hours. In the fire of a breathless shift, are we supposed to research what the pharmacy charges for the ointment instead of the cream? (The difference can be $100.) Or whether we should write for clindamycin in 300 mg or 150 mg tablets? Or whether patients can afford Zofran ODT or Zofran tablets? What are the breakpoints of the pricing? How do we get a patient Xarelto or Eliquis when it isn't covered by Medicare?

    Should we add the essential AeroChamber to the inhaler for an additional $20, which might make it unobtainable? How do we treat anyone for external otitis media for less than $100 without writing two scripts, one of them being a generic eye medication (for which you will later receive a phone call from the pharmacist who says, “Doctor, are you sure you meant to write for an ophthalmologic preparation?”)?

    This is bread-and-butter medicine, but if you don't know the prices or you guess wrong, it makes the difference between a patient getting the intended therapy and not, which is the very essence of why he came to the ED, and all because the cost of the bread and butter is not on the menu. Fixing that problem by remembering to give every patient a discount card is not really a fix.

    And at night, one is supposed to figure out to which pharmacy the patient would prefer that you send scripts depending on whether it is still open and which other 24-hour pharmacy may be near where he lives? As you hand him the discharge papers, which have been redone to reflect the other pharmacy he wants you to use, the nurse asks, “How is he going to get home?” Or “If you don't treat her pain better, she says she will walk in front of a car.” Or “She is wondering if she can have a sandwich before leaving.”

    Do the Job

    Emergency physician wellness is directly linked to these failures of emergent support of social determinants. Emergency physicians have neither the time, expertise, nor additional energy to MacGyver emergency social determinants from pharmaceutical prescriptions, rides, housing, and safety, to name just a few. Not only is it beyond what we should be doing, it is burying what we should be doing. It is preventing us from doing what we have set out to do.

    I have no problem being an advocate, but I am ill-equipped for social intervention. I am definitely not suggesting that hospitals invest in large-scale social interventions, and I know the chance of hiring out multiple emergency medicine social workers in this current environment is a pipe dream.

    The absence of a real public health system in the United States makes it easier to conflate emergency medical care with a social support system emergency. The most immediate cost to this confusion is the allopathic load it places upon the soul and the endothelium of the emergency physician. It is healthier for all to say, without malice, “I don't know; that is not a job I am well trained to do.”

    Instead of being just another voice in pain saying, “This is wrong. And I am tired, morally injured, burned out, and unwell,” as are the people with whom I work, I would like to offer a few small but potentially energy-saving tips to keep us doing the job we are set out to do.

    Don't MacGyver the social ills of your community or emergency department. If someone asked you to repair the engine on a combine tractor, you would rightly say, “I don't know how to do that. I would just spend hours tinkering and not make it run any better.” We should collectively say the same thing with the emergent social determinants in our emergency department. The patient doesn't have a ride, money for a prescription, food, housing, clothing, or a charger for his phone? You should certainly feel sad for him, even offer good advice, but to try to MacGyver social ills is not the job you set out to do.

    Set limits on preferential pharmacies after-hours. Spending your shift fixing the pharmacy errors from the last shift and trying to figure out the failures of electronic prescribing at 2 a.m. when no one is open and people change residencies and their pharmacies, or they have limitations on which pharmacies honor their insurance, this will quickly erode the desire to do the job you know how to do. Send them all to one pharmacy, the 24-hour one nearest the ED. It is OK to set limits by saying, “We don't honor preferential pharmacies after-hours.” Blame it on COVID-19; it's not untrue.

    Educate students, residents, and staff on prescription value, not on which medicine is recommended by the IDSA or the ophthalmologist on EMTALA call, but which one affordably works. If you can post it throughout the ED or manipulate your EHR to pop up the price on e-prescribing, even better. I know there is some regional variation, even among local pharmacies, but I am not sure why ACEP or some popular EM podcast hasn't taken up the topic of the top 25 price-savers for common prescriptions coming out of the ED. This is emergent social determinants of health 101 that we actually could have some control over.

    Avoid party-favor prescriptions. Take the typical patient who comes to the ED, spends several hours and several thousands of dollars of someone's charges, utilizes state-of-the-art technology, considerable time and labor of dozens of highly skilled professionals, and receives sacrificial efforts of empathy from housekeeping to radiology techs and security (if you still have these). At the end of this massive, frenetic, complicated, expensive, and resource- and time-consuming effort, one must consider first if he has actually gotten the diagnosis (diagnoses?) right. (And that is made easier by the fact that it is more often than not whether you didn't get it wrong and can allow the probably self-limiting ailment to run its course.)

    The next consideration is whether the patient really needs all those scripts or whether you are trying to emotionally pay them back (or emotionally pay yourself off) by giving them something for the time, effort, and expense for the diagnosis of “probably a virus.” We know (or should know from our training) that gabapentin, Flexeril, Tessalon Perles, PPIs, Bentyl, a Z-Pak, a steroid shot, and “trying an albuterol inhaler” are all part of a fairly worthless but very expensive therapeutic drama that is usually proven ineffective, especially for the substantial give-them-something category we see every day.

    Practice setting limits on trying to please people for what they desire because they heard about it on TikTok or their aunt is a nurse. Instead, politely offer expert scientific medical advice which they are not obligated to follow. It is OK to say that this disease course has not been shown to benefit from CT scans, lab work, IV Dilaudid, antibiotics, or anything they can buy over the counter. It is OK if they paid a lot of money and time for truth. And practicing having a professional backbone is good for your health too.

    We are the fastest and most elite drivers in our lane. We are driven to help the medical conditions of our patients at the bedside. We should stay in that lane. When we go out into the streets in territory and conditions in which we are not trained to drive, we are not really solving problems for the patient, and we are driving ourselves mad. Doing well at our job and being well at our job begin and end with doing the job well that we set out to do.

    Dr. Mosleyis an emergency physician in Wichita, KS.

    Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
    • kcmeyer911:25:32 AMEnjoyed this. Been in EM for more than 20 years in multiple roles including hospital admin, group admin, medical director, and grunt. I honestly think, though, that I've gotten pretty savvy at being a social MacGyver, but I'm sure this has hastened my slow burn in the specialty. I usually spend the first few minutes of questioning not about what is bothering the patient or family, but on questions like: Where do you live? Who with? How do you get around the house or go places? Who lives with you or helps care for you? Then the family seems shocked when I say, "I think regardless of what I find or don't find, we'll plan on admitting Mr./Mrs. Smith to the hospital because it doesn't sound like going home today is a good option. What do you think?" Of course, all of this is before we check anything. Though it's tedious, it is part of being a good doctor to be able to make a reasonable diagnosis (or non-diagnosis) and craft a treatment plan that the patient can actually follow. Unfortunately, this mixed up social web almost always takes more time that the actual medicine.