Hookin’ Up at Work (How to Get Fired)

I know I haven’t been updating the site recently, and I’m very sorry for that. I have a growing list of posts in my head, but I have been working too hard to get them down. Usually I don’t like to work this much, but I have had to pull several extra shifts because one of our docs got fired. Docs don’t get fired too much these days due to the whole supply-demand thing, but every now and again, some idiot takes it too far and becomes a statistic. This is his story.

Dr. Dumass, as I would like to call him, had a good thing going. Cush hospital, good position, great co-workers, and even a nice office. But apparently for Dr. Dumass, the nursing staff was a little too nice for him. Dr. Dumass was actually working on marriage #4 (I am not making this up) when he met Nurse S. Not only was this his fourth wife, but he had a litter of kids spread out all over the country from the last three. To quote Brad Pitt from Fight Club, “F$%#@* was setting up franchises“.

Nurse S was cute, pretty and they hit it off as friends from the start. She was having problems in her marriage and enjoyed talking to Dumass about her marital conflicts. He in turn would share with her his own marital problems with wives 1-4. They got closer and closer. 

Finally Dumass made a great suggestion, “Why not get divorced from our current spouses and get married to each other!”  I can only imagine that Nurse S was married to a drug addicted, alcoholic bridge troll with anger management issues, because I am not sure what exactly would be the attraction to a guy who has already blown through 4 wives and 10+ kids? Maybe she thought that she would be “the one“. Silly wabbit.

Things were moving along smoothly for our confused couple and they could hardly stay away from each other while at work. Either our darling little nurse would be in the docs documentation area or Dumass would be out at her nursing station whispering sweet nothings into her stethoscope. Just some advice for any of you readers involved in a similar relationship – you may think that no one notices, but in reality, everybody notices. Even the blind frequent flier behind curtain #2 knows about it because he overhears the gossip.

Before long, Dumass had already filed divorce papers and was waiting for wife #5 to-be to do the same, but that’s when trouble in ER paradise started. Nurse S comes in to work one morning and tells Dumass the hard news – she was having second thoughts. Suddenly, Dumass starts to have chest pain – you know the kind you get when you really want someone to feel sorry for you and give you that big hug you want so much and tell you everything’s going to be alright. But instead of calling in a replacement, Dumass decides to work himself up.

He goes and gets an EKG and Troponin heart enzyme done on himself. “Hmmm, looks like there might be some changes on this here EKG“, he says to himself. So he calls up the trusty cardiologist who tells him that he should get a stat echo. The echo ends up showing some wall abnormalities and is not conclusive (imagine that?). So the cardiologist tells him to high-tail it over to the cath lab. That’s when the proverbial crapola hits the fan.

Dumass tells Nurse S that he needs to get cathed … that indeed this might be their last moments together. The sappy soap opera romance is too much for her and she tells the charge nurse that she needs to clock out and take her dying beloved Dumass to the cath lab. There is no ER doc now and the chief of staff – a pathologist (autopsy doctor) – is called in to cover the ER. Must have been interesting for him to have his patients actually talk back to him.

At the end of it all, Dumass’s heart was perfectly fine – no blockages of any concern whatsoever. But folks over at admin weren’t exactly ready to throw the welcome back party for him. Instead they fired him for his Dumass behavior. He had taken this too far, and he put patient lives at risk. I actually thought he deserved an award for entertaining the hell out of the rest of us in the ER though, but decided I would keep that idea out of the suggestion box for now.

What lesson can we take from this story? I will quote a wonderful colleague of mine who once told me, “A doctor can be totally incompetent, but as long as patients like him, he will remain employed. But the moment he has sex with the wrong person or comes to work drunk or stoned, he’ll be fired in a heart-beat.” I guess Dr. Dumass can testify to this one.

Contributing Factors to the Current Physician Shortage

As early as 2005, predictions were being made of a coming shortage of medical providers for the United States. The reason that was primarily referenced for this coming shortage was a lack of adequate forecasting for an aging baby boomer population as stated here in a 2005 USA Today article:

The country needs to train 3,000 to 10,000 more physicians a year — up from the current 25,000 — to meet the growing medical needs of an aging, wealthy nation, the studies say. Because it takes 10 years to train a doctor, the nation will have a shortage of 85,000 to 200,000 doctors in 2020 unless action is taken soon.

Certainly, there is truth to this idea. I personally get numerous job offers on a weekly, and sometimes daily, basis. But there is something that these studies and articles are missing. A number of doctors are also getting so fed up with medicine that they are choosing non-clinical careers; careers where they don’t do patient care.  This includes working for drug research companies, writing/editing, educating and even leavingmedicine altogether. I read an interesting article on-line by Dr. Kent Bottles in a Physician’s News Digest from 1999 that discussed some of the discontent doctors are feeling these days:

There’s a 1998 survey by Levin of 6000 physicians in 22 different cities that revealed that 46% of all American clinicians often think about leaving clinical practice. That’s over 300,000 physicians in the United States that seem to be unhappy with the state of affairs. There are other indications about physician discontent that you might not think of readily. The number of disability claims by physicians has increased so much that some insurance companies no longer are writing disability insurance for physicians. Recently the AMA, one of the more conservative organizations of physicians, has voted to form a union. And another example I saw was an article that said that physicians are actually moonlighting by selling cleaning products and herbs out of their homes. So, for a lot of statistical reasons and for a lot of those more soft reasons, it looks like physician discontent is widespread and happens throughout the whole country.

I am also personally one of the aforementioned doctors who has thought of doing something else with my life. Medicine has changed so much that it has become unrecognizable to some of the older docs, and it can sometimes be down-right depressing for younger ones like me. Sure, all jobs have the good and the bad right? But to me it seems somewhat different when you dedicate 10 years of your life to learn a skill and then have someone accuse you of intentionally and knowingly trying to harm them.

I posted an article yesterday about how we, as medical practitioners, had misled people regarding the “threat” of Strep throat. I stated that, statistically speaking, the risk of serious side effects from antibiotic use for this condition outweighed the benefit. And in turn, I received comments that reflect what we all unfortunately hear in medicine from time to time. That we “don’t care”, or that we diabolically “want people to suffer”.

To me, this arrow stings the most. That someone would really think that because I make a certain medical decision, that this means that I intentionally wish to harm them or cause them to suffer needlessly. Maybe I’m too young and haven’t yet developed skin thick enough to deflect these barbs. And then again, maybe I never want to develop such thick skin. If I did, then I wouldn’t be able to muster the compassion for other people who do trust us and don’t want to just give us orders.

Overall, I think it is a global phenomenon of lack of manners that has developed. As a doctor, I am humble enough to say that I will not be right all the time, and I don’t have to be. What I am charged with doing though, is not harming my patient. If you are a patient and reading this, please remember one thing. You can always get a second opinion. You don’t have trash someone just because the one snippet you heard on Oprah or read in Time magazine seems to contradict your doctor’s decision or advice.

You Don’t Need to Come to the ER at 3am for “Strep Throat”

Among the more frustrating ER visits that you will never see on your favorite TV medical drama of choice is that of the 3am visit for possible “Strep Throat”. The sad reality though, is that this is something that we as a medical community have contributed to in a potentially large way. Some people are afraid of Strep because of the supposed connection to Rheumatic fever, while others are just uninformed (putting it nicely) and think that getting that holy prescription for Amoxicillin will make their discomfort go away in a space of hours (which it doesn’t). I guess I should be glad that most of them don’t come in trying to get Percocet to kill the pain (which doesn’t work well in this case either).

Regarding the whole strep and rheumatic fever issue though, I came across an article a few months back that addresses this issue. I will reproduce it at the end of the post for whoever would like to read it, but since it is medical speak to a degree, I thought it might be thoughtful to at least summarize it for those who don’t have the time or medical background to read it.

Basically, the article states that our current understanding that untreated Strep results in Rheumatic fever comes from only one large study that appears to be an anomaly. Two more recent and rigorous medical studies show that there is actually a relatively low risk of Rheumatic fever connected to Strep, and that the number of cases of serious side effects from our overly generous use of antibiotics far outweigh the risks of the limited number of cases of Rheumatic fever in this matter. It recommends against use of antibiotics in this case, but I wonder if the damage is already done? Trying to explain this to the average soccer mom would more likely result in a complaint than a “Oh thank you Doctor for looking out for our best interests!”.

In today’s internet society, too many people come to the doctor looking to get an order filled as opposed to getting an evaluation and medical advice. We keep saying that it is Burger King and we are not here to fill your order, but that message seems to have been missed by Hospital Administration and the general public.

For those who may be interested, here is the article:

Antibiotics for Strep Do More Harm Than Good

By David H. Newman, MD

Military and civilian medicine have always been intertwined, but nothing compares to the strange tale of Warren Air Force base in the 1940’s. Perched on the high plains outside of Cheyenne, Wyoming, the combat training center was, mysteriously, a bacterial cauldron. For more than a decade virulent strains of group A streptococcus caused unprecedented rates of pharyngitis among the trainees, and history’s worst epidemic of rheumatic fever.

A small cadré of military researchers at the base seized the moment, executing a provocative series of trials that tested the potential of antibiotics to prevent post-streptococcal rheumatic fever. Roughly 2% of the trainees given placebo in their studies developed rheumatic fever, while under 1% of trainees given antibiotics experienced the disease. For every 50-60 trainees treated with antibiotics, the researchers had successfully prevented one case of rheumatic fever. It was a small, but decisive victory.

Prior to the epidemic at Warren Air Force base there was little interest in ‘strep throat’. During the twenties and thirties in the Unites States, sore throat care focused on diphtheria, “the strangling angel.” The characteristic ‘bull neck’ and the dreaded grey pseudomembrane led to a gruesome, asphyxiating death for thousands of children each year. Comparatively, strep throat was a minor nuisance that often received little more attention than the common cold. But by the 1940s vaccination programs had nearly eradicated diphtheria, and antibiotics were becoming widely available. When the Air Force studies were reported in the early 1950s, they resonated. Rheumatic heart disease was common among adults, making its prevention seem immediate and intuitively important, and antibiotics for a bacterial infection made good sense. Identifying and treating ‘strep throat’ quickly became a staple of medical education, and little has changed.

The problem, of course, is that one can only prevent rheumatic fever where it may plausibly occur. Outside of Warren Air Force base in the 1940s, is rheumatic fever a plausible risk? Apparently not. There have been only two other cases of rheumatic fever ever reported in a pharyngitis study, both in 1961. In fact, despite large, contemporary studies tracking tens of thousands of strep throats in the general community, many of whom received placebos or no treatment, there hasn’t been a case of rheumatic fever reported in a study for nearly fifty years. When the incidence dropped to less than one per million in the general population in 1994, the Centers for Disease Control and Prevention stopped tracking rheumatic fever entirely.

At Warren Air Force base only 50-60 recruits were treated to prevent one case. Today, preventing one case would likely require antibiotic treatment for hundreds of thousands of strep throats, making it a mathematical certainty that antibiotics will do more harm than good. For each case of rheumatic fever prevented in modern practice, a few dozen patients either die or suffer near-fatal anaphylaxis, toxic epidermal necrolysis, colitis, or other antibiotic reactions, and many thousands more suffer diarrhea, rashes, and yeast infections.

Fortunately, rheumatic fever has been declining for a century, starting well before the introduction of antibiotics. While strep throat is no less common today, ‘rheumatogenic’ strains have dwindled, leading epidemiologists to conclude that antibiotics have little or nothing to do with rheumatic fever’s disappearance. Changes in hygiene, nutrition, population crowding, access to care, and changes in the bacterium are all felt to be important factors, which explains why the disease is now typically seen most in third world settings.

There are, arguably, other reasons to consider antibiotics for pharyngitis, but the evidence does not rise to support them. The Cochrane group estimates a 16-hour reduction in symptoms with antibiotics, but ibuprofen, acetaminophen, or a single dose of corticosteroids is as good or better, with fewer side effects. And while peritonsillar abscess may be minimally reduced by antibiotics, abscesses typically present primarily rather than after strep throat, and in most cases are easily treated. No studies have shown that antibiotics reduce the transmission of strep or reduce other complications.

The administration of antibiotics for strep throat, endorsed universally by practice guidelines and professional societies, is based exclusively on data from the world’s most concentrated epidemic of rheumatic fever. Using this to guide modern therapy is like administering antibiotics to prevent bubonic plague.

The essence of evidence is its ability to point us toward truth, and we must first understand what truth we seek. We do not ask whether antibiotics may be useful during a military epidemic of rheumatic fever. We ask a different question. We ask if antibiotics are beneficial for every day strep throat. Those who have written our guidelines and crafted our recommendations have, unfortunately, failed us. The strange tale of Warren Air Force base is a lesson in evidence: The only way to get an answer right is to pay attention to the question.

David H. Newman is the author of
Hippocrates Shadow (Scribner $26)