An appearance at trial followed by a lecture series left me craving a dose of reality.
This column is a nested narrative, but lest you think I am fulfilling the path of Mary Shelly’s Frankenstein or Ovid’s Metamorphosis, be assured that medicine is still the medium. The time frame is the last ten days of my life, during which I testified in a jury trial in defense of an emergency physician and lectured to 300 physicians in New York City.
First, the courtroom. Trials are the ultimate in omnipotence of thought – the infantile fantasy that thinking something can make that something a reality. You and I speak to each other in the language of science, which is mathematics. We speak of sensitivity and specificity. We challenge concepts like ‘acceptable miss rates,’ knowing that 100 percent and zero percent are not truly concepts in science as we know it. There is not, nor has there ever been, a perfect chart. Never. You can always say something differently; you can always record more. But in reality, we only do so much. All charts have the usual lies being perpetuated, which are only amplified by the electronic medical records, which pump up the billings but do nothing for the patient (or your defense team).
I was forced to deal with entries in a chart for both the doctor and the nurse which I know were impossible. How did they get there? How can the nurse record “ambulatory” on arrival when the patient arrives strapped to a gurney? The doctor had some equally difficult entries to explain. They simply never happened. But he checked a box as if it had happened. Was this a mistake? Did right really mean left? Again, magical thinking. We now believe we can undo the harm that we’ve done. Was there any great science here? Well, not really. This was blocking and tackling. Unfortunately, blocking and tackling are still a problem.
I can’t tell you how divorced from reality the courtroom has become. Jurors who were picked because they fit some demographic, racial or gender stereotype are intellectually imprisoned in an oral hell as attorneys on both sides flaunt ego and scientific ignorance to people who don’t quite understand, and quite frankly are bored. It is one objection followed by a sidebar followed by another objection. Strategy trumps truth. It’s what you can make people in that room believe that day. The history of medicine, science and reality be damned.
The judge barred me from discussing the fact that the patient in question was drunk and drugged out of his mind. Oh, no! That might prejudice the jury! I’m sorry, that’s just horse s----. Do you think that may have affected the physician’s ability to conduct a history and physical? Absolutely it did. And why this was not allowed in the courtroom is a gross miscarriage of justice. Truth in law is a matter of the imagination. “Truth” is what you make people who already know the end of the play believe was an error in judgment by a doctor who knew nothing at the time the patient arrived. Law is a philosophy which sets a fundamental alternative to Western Cartesian thought. It is an appeal to the Tao, not the left cortex. It invokes transformed language to confuse, not clarify issues. It is as Shakespeare said, “A tale told by an idiot, full of sound and fury, signifying nothing.” But through this doppelganger class, where epistemology and ontology collide, there are moments – maybe small moments – where justice might prevail.
I requested to be allowed to use the flip chart and pen to answer a question. Here’s our shot, I thought. Here’s our chance to teach the jury. I went to the board and drew out the neuro-anatomy which, quite frankly, the plaintiff’s so-called expert didn’t even understand. It should be noted that the plaintiff’s expert admitted under oath he had attended my lectures, to which I responded that I had never attended any of his lectures because he’d never been asked to give any.
After completing my second day on the stand, a car service was waiting to take me from New Jersey through the Lincoln Tunnel to Manhattan, where surely real truth and real science would prevail. I was lecturing at a medical literature course which I have taught at in New York for over 25 years. I like New York in June. And without breaking into a song, what’s not to like? It’s not too hot, there are people everywhere, and the naked cowboy still strolls through Times Square with his guitar. It’s like all is right with the world.
But just like my previous two days in trial, the gathering of physicians proved that these are troubled times in the kingdom of emergency medicine. The morning gatherings and coffee break conversation served as a nidus for the usual complaints about the profession.
First off, I can never really understand the comment, “I wouldn’t want my child to be a doctor.” That’s just not right. You’ve insulted what I do for a living. You’ve insulted a tradition of 5,000 years of good works. Don’t run around degrading a profession which has given us all great livings, interesting work and a reasonable modicum of respect. From the day you leave medical school, whether you graduated first or dead last, you are called “doctor.” This is a title which still carries respect; certainly more respect than being called “Congressman” or, worse yet, “Your Honor.” Even if you weren’t the brightest doctor, you were guaranteed a reasonable demand for your services. You’re in the top three percent of all wage earners in the country. By the way, what makes you think you would have less stress, be more famous or make more money in any other line of work? This is still a great and interesting job. I’d be pleased and proud if one of my kids went into medicine.
The second myth that was beaten to death at the meeting was the standard, “We work so hard.” That’s true, but not completely. I know people in investment banking, law and accounting who have bad hours and work very hard to make less money than we do. When I travel, I talk to everyone from bus boys to hotel staff to cab drivers. They are all working two and three jobs to hold it together. You’re not alone in putting up with hassle and stress. The difference is you make a lot more money. They were washing the windows on the outside of the Marriott Marquis Hotel while we were there. Risk management means something else entirely when you’re hanging on the side of a building at 64 stories. I’ll keep my job, thank you.
During the sessions, where we got into the real nitty gritty of our work, people really wanted to talk about the “What now?” of emergency medicine. We’ve been established as a profession for slightly over 40 years. We have built residencies, board exams and have a strong presence in Washington. What’s next? For instance, when push comes to shove, how will PAs and NPs be utilized? Unfortunately we found no consensus on what constitutes supervision and how cases were to be distributed. One physician said, “We cannot get by without PAs because we can’t hire enough physicians.” In response I advanced what I called the Nordstrom’s Theory of Emergency Medicine. That is: There is no shortage of emergency doctors anywhere within a 50 mile radius of a Nordstrom’s store. So the real secret to solving the emergency medicine crisis is to build more Nordstrom’s.
I don’t understand this crisis talk. I can remember when we had one residency graduate in emergency medicine. In two years, there will be 2,000 graduates a year. Let’s get real and stop using the term “crisis” at every drop of the blood pressure. The real question being raised is: How do we use other practice professionals? When several of us on the panel suggested, “You should see each patient, if only to say hello,” you would have thought we had committed a crime. From rural centers, I suggested we could discuss cases over closed circuit television. In the department, the use of scribes and other ancillary personnel should free us up to make sure that each patient is properly seen. As you might imagine, this was not received with uniform approval.
My suggestion is this: Stop the pity parties and start finding answers which don’t begin with the default attitude that without huge influxes of money, we are doomed. The earth precesses on a gyroscopic axis, which may have as long a cycle as 20,000 years. In the heavens, the true North Star will, in a few thousand years, will shift to the star Vega. Perspective and hope are needed. Cause and effect must be put in their proper order. Do people make the trains run on time or do trains make people run on time? Our roles are evolving. To stomp our feet gets us nothing but sore feet. Stepping back and finding where patient care can truly be effected, no matter who gives it or where it’s given, is where we need to be. Somehow we’ve lost our focus and the train of providing decent medicine has gone badly off the rails.