Gulliver vs the Lilliputians

I might just need an attitude adjustment. I have been a grumpy SOB lately. Herewith, an exploration of my current neurotransmitter imbalance.

I brought two patients to PACU (Post Anesthesia Care Unit, or “recovery room”) yesterday, each of whom was having a transient issue that might require swift intervention upon PACU arrival. The necessary equipment is always available at all PACU patient bays. In times past, this equipment was kept deployed, connected, and ready for use within seconds. That’s as it should be; PACU’s are critical-care units, and bad things can happen in a hurry.

However, in each case I had to wait, temporizing as best I could, while the PACU nurse fiddled with peel-apart packaging to free the equipment; or tried vainly to dislodge the gear from plastic storage bags that wanted to grip it, while other loose components fell from bag to floor, and rolled under the stretcher, out of reach; or struggled to get suction or oxygen tubing freed from its bound coil, and connected to its wall outlet. Time wasted for no reason, because some higher authority decided, on poor or no evidence, that having this essential non-sterile gear opened and ready to go poses some putative infection risk. The PACU nurses’ management has forbidden them to open these items until they are needed. Happily, things turned out well for my two patients yesterday, despite the institutional and regulatory hurdles we had to clear. But why should needless struggle have added to the stress of the situation?

Physicians are trained in a scientific tradition that nevertheless takes into account the innate variability of the “biological units” we call patients, and the unknowability of many things we have to leave instead to art, or judgment. Within these limitations, we do our best to follow the evidence. But we all feel at times that “evidence”, especially the incomplete or inaccurate variety, is used as a cudgel to put us in our places, or to advance the ambitions of certain groups of allied professionals, rather than to advance the cause of patient care – or at least to prompt further search for the right answers. Gulliver bound by Lilliputians, if you must have a literary metaphor; or insects biting at one’s ankles.

Physicians have historically sat atop the money and prestige heap within the healthcare industry – a collective status I freely admit has not been merited in all cases by the individual ability or character of my predecessors and colleagues. Medical-school admissions and subsequent training tend to select for driven individualists with strong egos who don’t always play well with others – an obvious downside to the upside of a world-leading level of training and capability among the US physician workforce. Though the culture is changing, you can’t have the one entirely without the other. Most physicians cherish the story, often true, that they succeeded by dint of demonstrated competence and grueling labor, and apportion respect only to those who have earned similar stripes.

Unfortunately some of my colleagues have approached their careers with a sense of entitlement, rather than the required servant heart. Resentment and jealousy have followed – understandable reactions when others see people they judge as no more virtuous or harder-working than themselves getting paid much better, and enjoying much more deference. To that I can only respond that I can’t help what life choices others have made (the opportunity cost of a decade forgone during training come to mind here), or the behavior of those who came before me. I have to do the best I can each day.

The ability and willingness to shoulder responsibility is the final differentiator. Someone has to make the hard decisions, and live or die by them. When you look around during a medical shit-storm and find that everyone else is looking at you, then it’s likely you’re the doctor in the room. If you want to trade places with me, you can have my paycheck and perks, such as they are. But the marketplace has rewarded my willingness and ability to make such decisions at a value determined by their relative scarcity. I make no apology for that. But I’ve never claimed to be a more-worthy human being based solely on my degree; I leave that judgment to my family, friends, and posterity.

Today I did a couple of cases at another of our facilities, a place I enjoy going because the staff there are friendly and helpful, and the surgeons pleasant and capable. I’d like to think they reciprocate the courtesy and respect I accord them. However, there’s someone there – let’s call him/her Clipboard – who I absolutely know will be on my ass if I wear my LSU or Alabama cloth scrub cap. I’m not special; Clipboard is on everyone’s ass about something, all the time. (Just ask them, as I did today.) Someone up the Lilliputian food chain decided that disposable paper bonnets pose less infection risk for patients; cloth caps are verboten. Like your parents used to say, “because I said so.”

The evidence for this claim is sketchy at best, and recently refuted by the only controlled, peer-reviewed study that’s looked at the matter. They are certainly hotter and more uncomfortable to wear, because they are hermetically sealed against sweat evaporation. But hospitals, with the government and payers (increasingly one and the same) bearing down on them over infection rates, often seem more concerned about doing something than about doing something effective. And, if I’m being candid, biting the ankles of people you’ve long felt have disdained you (real or imagined) can be soul-satisfying to a certain sort of person.

Today I wasn’t in the mood to be hassled, so I sweated quietly under my blue paper bonnet, and Clipboard didn’t trouble me. Except to drop off my mandatory safety-instruction packet while I was in the OR holding open someone’s airway during surgery. I kid you not. I had to sign for it with my right hand while lifting a chin with my left. Had I politely asked, or pointedly told, Clipboard to get the f&^% outta my face, I’d have been labeled a Disruptive Physician, with potentially severe career implications. The packet is the same as last year’s, and the one before that; its delivery no doubt gave someone in Legal the frisson of satisfaction that only comes from having Covered One’s Ass. I’d say that this vignette neatly encapsulates the state of modern medical practice.

And still the Lilliputians weren’t done with me. I got a mass email from my own group’s administration asking us to moderate our use of an expensive anesthetic drug at one of our facilities. It seems our use of the drug is the highest among all of this hospital chain’s facilities in our region. Big budget line items attract attention, but ideally they should also provoke inquiry and analysis. The question should become, is our use of the drug appropriate? Or, what is the cost of the problems we’ve avoided by using a more-expensive, but much more effective, drug? No one can, or is, tracking that.

This hospital’s pharmacy can produce in minutes a report detailing exactly what drugs I’ve used, on which patients, since I started working there. How about identify the individual anesthesiologists who are “excessive” utilizers, and email them directly for corrective education – or maybe even plumb their reasoning for using the drug? Instead, I get an anodyne form email, no doubt at the hospital’s behest, that educates no one, informs no one, leads to no conversation or process improvement. It’s an item that Clipboard would have checked off his/her list of to-do’s, while sucking a drop of blood from an ankle vein.

And the day started with not one but two incidents of road rage directed at me en route to work. I’ll spare you the details; but you’d think in a state where people are consuming a lot of legal weed, people would be more chill. But Denver drivers are the most aggressive and rude I’ve encountered anyplace I’ve lived.

So yeah, I’m grumpy.

Michael Sebastian @mikeseb