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 “You know what?” I said philosophically as I put my feet up on the table and took a sip of coffee from a Styrofoam cup, “I like lawyers.”

 “I do too,” said my partner without hesitation. “If they are cooked properly.”

It was a rare slow moment. Well, it wasn’t really slow. There was just a log jam in triage. And it was taking forever to get patients into the rooms. So I had a few minutes with the colleague whom I was relieving before he left me for the night and the madness resumed.

“No seriously,” I continued. “They may be cold-blooded, slimy little bastards, but if you ever get into a problem and you really need a lawyer, at least he’s YOUR cold-blooded slimy little bastard. He will do anything, and I do mean anything, to win your case. He will lie, cheat, steal, sell his grandmother, anything to win your case. In a twisted sort of way, I really admire that.”

“We, on the other hand, talk about doing everything for the patient,” I continued. “But in reality we’re doing things to the patient that can be outrageously expensive, an unbelievable hassle, and sometimes hellaciously painful. And is it always for their benefit? Be honest. Not always.”

My partner screwed his face up like he had heartburn.

“From the very first moment they are in the ER, we are fitting them into our system instead of meeting their needs,” I said.

“What are you talking about?” he said, getting irritated.

“Have you ever been a patient in an ER? I chopped my fingertip off a few years ago hooking a trailer up to our minivan. When I got to the ER, I had to stand in line to talk to a woman through a waist-high hole in a plate glass window. She never looked up from the computer when she asked me why I was at the ER. I just shoved my bloody stub of a finger through the hole. She acted irritated like I was flipping her the bird.”

“You should’ve just called plastics down to take care of you,” he said with a shrug.

“First, I didn’t come here. But yes, I did. And you know how pissy everyone gets when a patient ‘tells’ the clerk what they want.”

“Did you tell them you were an ER doc?”

“Of course. But I felt like I was throwing my weight around. It was a little embarrassing. Believe it or not, there were actually people worse off than me sitting out in the waiting room. The staff was very nice to me and took me right back, but that even made it a little worse. Because I saw that sometimes the patient comes first, and sometimes priority goes to the system. I don’t think it’s always been that way.”

“What do you mean?”

“I don’t know. What about house calls? In the old days, when the patient was sick as a dog, the doctor went to see the patient at his home, in his bed. He didn’t tell him to go sit in some cold waiting room.”

“Hey, I know you’re old, but you’re not old enough to remember house calls,” my younger colleague said with a smirk. He loved to rub in the “old doc” comments. But he was right. I was recounting a bygone era that I never experienced. “So what changed?”

“That’s a good question. Money, maybe,” I said.

“Maybe the old docs just got overwhelmed with the number of patients and couldn’t go see them all, so they sent them to the ER.”

“Maybe they didn’t want to be too tired to play golf the next day.” We both nodded our heads in agreement.

“I can tell you when the change occurred,” the nursing night supervisor chimed in. Now this gal was old school. When I first got to know her she still wore a nursing cap. “It all changed in the late 60’s when everyone got Blue Cross/Blue Shield and Medicare. That’s when the patients started coming in droves and attitudes changed. People no longer paid for care out of their pockets. Medical care went from being tailored to the individual to being mass produced. We started using treatment protocols, standing orders, and preprinted histories and physicals, just to make things more efficient.”

“You’re not saying that you are against standardization, are you?” said my colleague. He had a side interest in ED operations and was always looking for new ways to streamline the process.

“Not if you are making Chevys or burgers,” I answered. “But caring for a sick person needs to be a little more individualized. When we try to fit people into protocols, they don’t always fit. And maybe it’s not so much about process, but about how process impacts our perspective. We start to look at patients as a group instead of individuals.”

“Like the elderly woman that I saw tonight who broke her ankle.” I could see that my friend was starting to see the picture. “She has no way to get around the house. She’s not safe on crutches. I’d like to admit her over night, until her daughter from North Carolina can get up here to take care of her. But Medicare won’t allow it. You know the story: If we admit every old lady with a broken ankle we’ll break the national treasury.”

I shrugged. “Oh, by the way, what DID you do with her?”

He tossed his head in the direction of Room 3. “No, the question is, what are YOU going to do with her?” I looked over to see her happily munching away on a bag lunch.
“I guess that’s one way to handle it,” I said. “Oh and by the way, Medicare IS breaking the national treasury.”

“Yeah, I’ve heard you say that before. ‘39 gazillion dollars in the red over the next however many years.’ So which way do you want it? Save the money and send grandma home to fend for herself in the dark tonight or blow a wad on keeping her in the $500 per night hospital? You can’t seem to make up your mind. And you can’t have it both ways.”

“That’s exactly right...and wrong. I mean the question is right, but the answer is wrong. It is a very tough choice. But I’m not the one to be making the decision. The patient should be making that decision, based on how important it is to her. Some people would elect to go home and tough it out, while others would pay to stay.”

“But she should only be allowed to make that decision if she is the one who is paying for it.

“Exactly. And it is my job to give her the information she needs to make a decision that she feels good about. I don’t work for the insurance company, the hospital, or the government. I work for her because she is the one who pays me.”

“Hey, I’ve gotta go and you need to get to work. But tell me one thing. You don’t really like lawyers do you?”

“I’m just like you. As a group, I can’t stand them. But if I slip and fall on the ice in the parking lot, I’m sure that a half dozen of those little bastards will try to pick me up and offer to drive me home.” 

by Mark Plaster, MD  
 

Comments   

# Not a Lawyer 2010-01-18 20:30
“If they are cooked properly.”

That, and a lot of barbecue sauce.

Seriously, it's popular sport for everyone (myself included) to hate lawyers. Until you need one. And then, depending on the disposition of your case, you either love your lawyer, or you hate lawyers even more than you did before.

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# Dwight Burdick 2010-01-23 07:59
"It is not patients who should comply with their doctors' demands, but doctors who should comply with their patients' informed and considered desires."
S. Holm
Journal of Medical Ethics, 19, 108-110
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# So what WOULD have happened in The Good Old Days?DensityDuck 2010-02-01 18:57
"Like the elderly woman that I saw tonight who broke her ankle...She has no way to get around the house. She’s not safe on crutches. I’d like to admit her over night, until her daughter from North Carolina can get up here to take care of her. But Medicare won’t allow it."

...so what WOULD have happened to this patient in the days before Managed Care? There's an important element in the story that's not really discussed.
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