WhiteCoat

A Nation of Enablers

One of the docs I was working with (who is much more “cerebral” and well-traveled than I) made an interesting comment as we watched a noncompliant epileptic patient being wheeled past us into the room on a stretcher.
“We are such a country of enablers,” he said. “In this country if someone doesn’t take their medication and has a seizure on the side of the road, we send a big taxicab with lights spinning and sirens blaring to go pick them up and bring them to the hospital. We put them in a nice warm bed. We give them a meal if they are hungry. They get to watch cable TV. Several well-educated servants in scrubs tend to their every need. We even give them the medicine they should have been taking through an IV so they don’t have to swallow it. We then send them home with a prescription for more medication in their pocket and give them a survey to make sure that they enjoyed their stay. And if they don’t have a ride home, we get another big taxicab to take them home and tuck them into bed. Two days later when they don’t fill the prescription and have another seizure, the same big taxicab goes out to find them and we repeat the same process all over again.”
I smirked at his pointed cynicism. Then he continued.
“In Mexico if someone doesn’t take their medicine and has a seizure on the side of the road, they wake up on the side of the road … with no sneakers and with no pesos in their pocket.”
I wonder what the rate of seizure medication noncompliance is in Mexico.

For an example of a different kind of enabling, see this post on ER Nursey’s blog.

One patient I saw was too large to be taken out of their home through his front door. The fire department had to remove a window and take the patient out of the second floor with a crane. Then the paramedics had to bring him on the back of a pickup truck and drag him into the ED on blankets because he wouldn’t fit on a stretcher. At some point will society agree that if you allow yourself to get this big that you are acknowledging no one may be able to treat you in the event of an emergency?

—————–

SEE ALSO this post and the comments on a separate discussion of enabling medical patients.

27 Responses to “A Nation of Enablers”

  1. ERnursey says:

    Since we have been dealing with an ‘every other day seizure and trip to the ER patient’ this really struck home. I went on a medical mission to a country and was amazed to find that the only dialysis they have was for the tourists or those who could pay for it themselves. The guide told us that people have kidney failure because they don’t take care of themselves so why should the government pay for it. Why indeed?

  2. Nurse K says:

    I read somewhere that when the ambulance picks you up in Mexico, they swipe your credit card in the back seat too—no money, no ride.

  3. DocsGirl says:

    Is it bad that I just smiled at the credit card comment…? :-P

  4. markps2 says:

    IMO “A nation of enablers” is brought to you by psychiatry and the drug Co. They want to sell a treatment/pill for gluttony and all the bad feelings and bad decisions people make. “Harvard Researcher Says 50 Percent Of America Is Mentally Ill” Link to furious season

  5. I found out about your blog from Scalpel or Sword. I love your post, and I’m adding you to my blogroll.

    MJ

  6. Steve says:

    Markps2…I’m not discounting your guess at the cause of “a nation of enablers”; I would just like to add some insight. I think it all started in the 60’s with the liberal social policies that were generated at that time. People were “officially” allowed to acquiesce their responsibilities of life. The great government was going to care for them from the cradle to the grave. No need to work hard for the “American dream” because it would be given to you!
    So now after 40 plus years…what do we have?

    Steve

  7. We have the greatest healthcare system here in the US!! Don’t we? We spend quite a bit of money relative to many other nations.

  8. Isabelle says:

    In Mexico, when you get too big to be taken out of the front door to the hospital, you just lay there until you’re small enough.

  9. nocturnalRN says:

    I just found your blog and am digging it so far. I am blog rolling you as well.

  10. I agree, there are far too few consequences for poor health decisions these days.

  11. votermom says:

    I don’t understand your post. My kid had non-febrile seizures at age two — I guess I was wrong to call 911? Lucky we had insurance, because the ambulance tried to bill us $900 for ride. Got a bill from the ER too. Sorry we are such enabled wusses I guess I should really have strapped the stiff kid into the car seat and driven to the ER, right? I know someone who actually did do that — one year old went into shock from an allergen, parent panicked that the ambulance wasn’t there yet, and drove the kid to the nearest clinic, except because of the panic, they crashed and both got airlifted to the hospital instead. Yeah, that was a much more sensible outcome.

  12. Dr. WhiteCoat says:

    Votermom, you need to re-read the post. It applies to “if someone doesn’t take their medication and has a seizure…” Bringing a child with a seizure by ambulance is entirely appropriate. The question raised was whether this country is enabling adults who repeatedly fail to take their seizure medication and then are repeatedly brought to the ED to have medical staff give them their medications. Or whether we are enabling people who weigh 700 lbs to continue eating eating more by forcing ambulance companies to purchase larger equipment and beds that can accommodate people who weigh so much.
    Obviously this scenario wouldn’t apply to someone who has never had a seizure before or to someone who has seizures despite therapeutic levels of seizure medication in their system.
    Should society spend tremendous amounts of money to help people who refuse to do simple things to help themselves?

  13. votermom says:

    So is it the paramedic or the 911 operator who gets to quiz the person having a seizure: “Did you take your meds? What’s that? You can’t afford meds? Don’t you have a job? You do but no insurance? because of your pre-existing condition? Just let me check here … hold on … um …computer’s slow … hang on … Ok, congratulations! You can be transported to the ER!”
    Thanks for the clarification, that makes sense now.

    Sorry for the snarkiness. Your post just triggered it. Your other posts are ok with me, in fact I think you’re a good writer. I grew up in a poor country, no 911 service, very poor health service, and in case of a fire you better have cash to bribe the firefighters with or they won’t hose down your house — it really upsets me that a lot of people in the US think that’s a good model to work towards.

  14. Christine says:

    I don’t agree with the comment that people get kidney disease from poor health decisions and should only have access to dialysis if they can pay. While uncontrolled diabetes and htn can lead to kidney disease, some people just get the short end of the stick.

  15. melissa says:

    just because you don’t understand med non compliance (through the biomedical lens) doesn’t mean it doesn’t make sense. I hope medicine will continue growth in the direction of holistic understanding (bio psycho social spiritual) perhaps then interventions to increase compliance and will replace irritation with understanding and encouragement. Human beings are simply much more complicated than the mechanisitc world view might suggest. I am saddend and astonished at how quickly we apply blame when our efforts fail to adequately address these problems, this would indeed consitute the condition known as enabling.

  16. JaneMarieMD says:

    I understand why the well-traveled doctor commented as he did, but somehow it doesn’t feel very good, does it? I think this is because it suggests he may lack compassion. But all of us in medicine lapse into pretty judgmental comments and jokes from time to time. Is the epileptic patient really different from my Mom, who didn’t stop smoking soon enough to avoid lung cancer? I don’t think so. We all do things that don’t seem rational, and fail to do things that others would say would be in our best interest to do. There might be some good reasons why the patient hadn’t taken his seizure meds, or he might be one of those few that are wildly, extremely non-compliant (these patients visit ERs disproportionately I think; I don’t believe there are quite so many of them in the general population as it sometimes feels when you are the doc that has to care for them!!). If you are able to talk to these people a bit you can often find a reason for the noncompliance: money; lack of understanding; dementia or mood problems; side effects of the medications; etc. Of course, that doesn’t mean you can remedy the underlying cause of the noncompliance!! I believe most people make decisions according to their own interests, that may not be mine, and sometimes aren’t comprehensible to me, but that is their right and I believe most of the time this works for people. I feel satisfied after an encounter with a patient if I think I have a handle on what they are doing with their health. Sometimes it takes a long time to get to that point (maybe years), and with some patients I never do.

    The other troubling aspect to the comment is the suggestion that perhaps we as a society shouldn’t take care of people who don’t behave as we think they should. This seems sensible at first, but who is going to decide what we should and shouldn’t pay for? Probably the majority of Americans are eating too much, not exercising enough and are overweight–should those who go on to develop diabetes, hypertension, heart disease, arthritis and the many other problems that are PARTLY due to these poor habits not have their healthcare paid for? I’m with the other commenters who suggest it just ain’t that simple.

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  18. Concerned Mother says:

    What happened to the part about people needing dialysis because they didn’t take care of themselves? Did you edit it out? My son was born with renal failure, hydronephrosis, Grade 5 bi-lateral reflux. He’s double implanted so he’s refluxing on 4 ureters. One kidney has been destroyed since birth, the other is ½ ruined. I did nothing and neither did he. So, he doesn’t deserve dialysis? This is due to some sort of medical non-compliance in the eyes of your cerebral friend on one of his mission trips? I hope he has as much compassion for his fellow American as he has for his mission trippers.

    I get real concerned when I read these medical blogs. They resonate with distain and disgust for the majority of the patients served. Most of the bloggers see a drug seeker or a PITA around every corner. If you are unhappy in your profession, then leave. There will always be people who work the system.

    If we want to fix health care, we need some sort of single payer system. Have you ever looked at the websites of various insurance companies and HMOs? They have more executives than I care to see. If we had one system for payment, everyone would know what was covered and how much. There would be no need for Vice Presidents of: Sales, Marketing, Communications, Medical Operations (why does an insurance company need this? Oh yes, I forgot medical decisions re no longer between patient and doctor), Pharmacological Operations, Business Retention, etc. That is a boatload of savings right there.

    As for the rest of the so-called problems with switching to a single payer system? We already have waiting lists and no choice. If your doctor doesn’t participate, you need a different one or pay cash. If your Primary Care Physician (PCP) refuses to refer you, you pay cash. The insurance companies and HMOs say that they are not stopping you, they just won’t pay for it. In most cases, that is the same thing. Hedis, JCAHO, all designed to make more work, cost more money without contributing a damn thing.

    As a caregiver for 5 disabled people, I am in and out of hospitals all the time. Even top 100 hospitals. Behind the hand rubbed cherry lobby with water fountains, the plasma TVs and saltwater fish tanks in the waiting rooms, lies filth. It’s third world as you roam the corridors behind the scenes. One when my son was hospitalized, there was vomit in the room. No one could tell how long it had been there, all dried up. Someone had vomited on the TV channels listing card and then it was stuck back between the phone and the monitor on the table. Dried blood on the gurney, not ours, since we hadn’t been stuck yet. Once we got a room with carpet in it. Who puts carpet in a patient’s room?

    Thanks for the rant. But, I am even more wary of my MDs now. I am very concerned that the blogging is reflective on the industry as a whole.

  19. Anna says:

    This doctor thinks of nurses as ‘well-educated servants’… This says all I really need to know about this ‘cerebral’ and ‘well-travelled’ buffoon.

    I agree with ConcernedMother that the tone of all too many medical blogs is simply dripping with condescension for those in need of medical care.

    Melissa is also correct that there are reasons for ‘non-compliance’ that often seem quite rational and logical in the mind of the patient at the time.

    I don’t think ‘enabling’ is the main problem in this country today. Rather it is the unchecked arrogance of some (not all) Medical Doctors who have an opinion of themselves preposterously inflated far beyond their actual value to suffering patients.

    Sorry. Just my opinion.

  20. Bonnie says:

    Melissa is also correct that there are reasons for ‘non-compliance’ that often seem quite rational and logical in the mind of the patient at the time.

    Well, just because they’re ‘rational and logical’ in the mind of the patient doesn’t mean they’re rational and logical in the real world.

    I have always hated that philosophy. Just because I ‘perceive’ the sky to be purple doesn’t make it so. Just because I ‘think’ I have reasons not to take my meds doesn’t mean those reasons hold water, or that other people should go along with said reasons.

    I’ve thought about writing a story (and if we ever go to a single-payer system, I wouldn’t be surprised if this actually happens) wherein if you don’t have a yearly physical and other recommended screening tests, and if you don’t keep your weight down–even if this means gastic bypass–or if you smoke or take drugs or don’t take your meds correctly–you don’t get medical care. Period.

    Sure, this is non-compassionate, but by crackey you get tired of dealing with idiots.

  21. Mary says:

    I agree with your post because I can see how “frequent flyers” expecting everyone to pick up the pieces again and again and again can get very irritating indeed. But is it one or two people coming in repeatedly, or just a lot of people coming in once but with the same problem?

    I bet there’s no one here who can say that, in the hurly-burly of their everyday life, they would manage to take several medications a day at exactly the right times and have everything they could possibly need on their person every time they leave the house, every single day for ten, twenty, thirty years or more. Forgetting your tablets is a bit like forgetting your keys or your purse, you know it’s important, you try to remember, but sometimes it just happens.

    A teenager I know who has epilepsy has mucked up his medications badly enough for it to cause seizures and hospitalisation once in the last five years. He didn’t do it on purpose (there were a lot of life-events happening to him and his family at the time) and personally, I think one major cock-up in five years isn’t bad going. Yeah, I think he should have been treated, and treated sympathetically at that. I don’t think he should be treated like dirt just because to the doctors, he’s the N-th person they’ve seen this week to get carted in because of a medication error, rather than an individual who has made a one-off honest mistake.

  22. Tom Reynolds says:

    I agree with ConcernedMother that the tone of all too many medical blogs is simply dripping with condescension for those in need of medical care.

    Here is the thing – you might go through your day and meet only one person who is a waste of oxygen. We see many, many more. Like the police we find ourselves regularly going to alcoholics, drug users and general abusers of the medical services. It wears you down after a while.

    Consider the type of person who annoys *you* in your day job, if you work a till it might be the person who takes forever to load their shopping on the belt, if you are a teacher the parent who refuses to accept that their child’s bad behaviour is anything to do with them, or the photographers who try to take pictures of squirming children.

    All these things annoy, some more than others.

    But it doesn’t mean that we don’t treat those people the same as the nicest little old lady. We just snark about it a bit behind their backs – something I’m sure that we are *all* guilty of.

    (Or to boil it down – us medical types are human beings as well).

    And the ‘well-educated servants is I suspect what the patient thinks, not what the doctor thinks…

  23. tristan says:

    Let us take a deep breath, these kind of comments are rampant in the industry(I drive an ambulance), they are a coping mechanism. The truth is that noone wants to return to the Mexican style of health care. It is frustrating realizing the futility of caring for people who won’t care for themselves, but caring for people is important.

  24. cheryl says:

    Nobody in their right mind would ever suggest that a parent not call an ambulance for their child having a seizure. The frustration that you read in some medical blogs is because, despite our best efforts, people do not take responsibility for their own health. Then, those people blame Dr.s and nurses for their chronically high blood sugar, their seizures that don’t respond to NO treatment, etc.

    As one of my medic friends says when a patient we get several times a month with a problem that they wouldn’t have if they just complied with treatment. ‘Gee, I don’t know what’s wrong. They’ve tried nothing and nothing seems to work.’

    On another note. If reading about the few patients in the medical blogs that just make us cynical and frustrated upsets you….don’t read them. For every one of those patients, there are literally hundreds of patients that we do see, and do help and for most of us there is not another job in the world we would be happier doing. And, just so you know. Even the patients that we see frequently that refuse to be compliant and are pains in our butts, we still treat them with respect. Sometimes our blogs are just our way of venting. A PA friend of mine says working in the ER is a lot like acting sometimes.

  25. EmergencyEmm says:

    Hehe, I love this post.

  26. jen says:

    I have a friend that I have known since I was 12. Her whole family is heavy, her father is a diabetic. She is now quite heavy and would love to have the opportunity to have a gastric bypass or medical assistance to get her weight under control. Her problem? She can’t afford it. She could save a ton of money now by heading off future health problems related to weight if she could, not to mention increase her self-image and have a better chance of earning more etc etc, but she can’t.

    My family also has a predisposition to weight issues. My grandmother has always had an extremely large chest which ended up causing such severe back problems it impeded her ability to exercise. I also have ended up with large breasts, and I really wish I hadn’t. I’m not obese, but I am a little heavier than I would like. I worry that I will have problems as I age due to weight issues, and I also worry about my chest causing structural problems, but when I mentioned the family predisposition to a previous healthcare provider he mentioned my concerns were merely ‘cosmetic.’

  27. [...] die a slow death from his renal failure. Most families will just call “911″ and the red taxi with the spinning light on top will come to pick grandpa up at his home and take him to the emergency department. At that time, [...]

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