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Can ER doctors avoid mood triggers?
by Kevin Pezzi, MD
In another article, a fourth-year medical student with a diagnosis of bipolar disorder asked me about choosing a low-stress career to avoid mood triggers. ER doctors frequently experience a variety of mood triggers. Here are just a few:
Imagine beginning your day by listening to patients swear and scream at you for an hour because they arrived at the ER hours ago, when you were still at home.
Imagine trying to work as fast as possible to catch up and having to work with folks who smugly know if they screw up, you'll be the one sued. Hence, when you kindly ask them to please put the charts in the correct bins so you won't waste precious minutes trying to find them, you might receive helpful cooperation or a half-ass effort that perpetuates a seemingly endless cycle of repeating the same mistake of misplacing medical charts. Many charts were so hopelessly lost that I spent months developing an electronic chart-locating system.
Imagine being handed an obviously incorrect EKG by a new nurse who repeatedly refused to repeat it even though I've spent more time studying the heart than the whopping two years she spent after high school to become a nurse (I described this arrogant nurse on another page).
Imagine working with nurses that range from very bright and highly competent professionals to ones who return from breaks with booze on their breath, who make such outrageous errors they couldn't be innocent mistakes but instead deliberate sabotage of patient care. Imagine bringing these mistakes to the attention of the nursing administrator and being curtly told that what nurses did on their breaks was none of my business.
Imagine working with an ER technician who did something that made me wonder if he'd just raped one of my comatose patients who was young and very attractive.
Imagine a world-champion kickboxer kindly informing you, seconds before you're about to peer into his eyes with an ophthalmoscope, that he might cave your skull in during that procedure by taking advantage of your inability to see what's coming. You'd like to run away from such a threat from someone who looks as if he could bend thick steel bars with his bare hands, but you have a professional obligation to treat this man, whose aggressive behavior might be just another symptom of the head injury he experienced.
I've had patients with personal hygiene so bad that I began to vomit in the ER, years after exposure to sights and smells that gave me the ability to tolerate almost anything. Imagine that you've worked for a decade as an ER physician, seeing things most nonprofessionals cannot imagine, when a patient unintentionally assaults your senses with a whole new level of noxiousness, with sights far too gruesome for horror films and odors that make feces seem like perfume.
Imagine arguing with hospital vice-presidents who don't care if patients die as long as the dollars gained by seeing too many patients in too little time offsets the loss of any malpractice settlements that might result.
Imagine hospital policies and procedures that make medical mistakes virtually inevitable, even when the doctor did everything correct. And who gets the blame? The doctor, of course!
Example: One hospital I worked at used easy-off stickers on EKGs and x-rays to identify the patient. On multiple occasions, technicians switched those stickers to the correct one while the doctor was reading the EKG or x-ray or even after the doctor went home! Thus, the doctor thought he or she was reading an EKG or x-ray from Mr. Jones, for example, but it really came from Mrs. Smith.
This is almost certainly the explanation for why my boss, a very intelligent and highly competent ER doctor, sent a patient home earlier in the day. When the patient returned with intensifying chest pain later during my shift, I looked at the EKG taken before, which my boss read as normal even though it showed very obvious evidence of a myocardial infarction (MI or “heart attack”) that could be instantly spotted by medical students.
The chance of my boss not spotting that MI is about as likely as Hugh Hefner forgetting what women look like—utterly unthinkable. What almost certainly happened is that my boss correctly read the EKG given to him, taken on another patient but labeled with the name of the patient I later saw. The ER staff did the sticker switcheroo after my boss read the EKG without telling him, just putting the EKG in the chart as if that made everything OK.
The inevitable lawsuit for a delayed diagnosis of MI might seem attributable to my boss, but it actually resulted from the nitwit administrators and unthinking staff, none of whom were sued. Hence, when you hear about doctors being sued, keep in mind that many mistakes result not from purely physician errors but from medical policies and procedures designed by people who are either bereft of common sense or behave as if they don't give a hoot because if any mistakes result, the docs will take the heat.
Imagine working in a state in which the legislators are so clueless that their laws permit doctors to be sued even when they did a perfect job (not just an average job, which is all that is required of them), leaving docs wondering what the heck they must do to shield themselves from frivolous lawsuits.
Imagine receiving a death threat from a patient who really seems serious about it, years after you've been acclimated to such abuse, with 99% of threats going in one ear and out the other, knowing they were just blowing off steam. But then there's that man with a shotgun and a threat so credible you seriously wonder if you'll be alive tomorrow.
Imagine being repeatedly punched by a patient and then having a hospital administrator suggest it would have been better to allow this highly intoxicated and suicidal patient to leave the ER on a dark moonless night and walk 40 miles home, even though if she were struck by a car en route, you as the doctor would be the one sued.
Imagine having patients who make more money than you (such as strippers) talk about how much money you have.
Imagine having your income determined not by your skill level or the free market, but by insurance companies and politicians who have a vested interest in reducing your income. Ever see a dentist work the night shift, weekends, or holidays? Ever see a dentist devote more years in training than a doctor? Ever see a dentist work more hours per week than a doctor? Ever see a dentist work with patients who made them vomit or fear for their lives? In my case, the answers are no, no, no, and no, yet the average dentist now makes more than an average physician.
Imagine being so swamped with patients that you couldn't possibly do everything you should even if you could work four times as fast (for an actual example of how hectic it can be to work as an ER doctor in a busy, high-acuity ER, read 15 Minutes in the Life of an ER Doctor). I never worked in a hospital that called in an additional ER doc when the emergency department was flooded with patients; they had no solution other than to cut corners and delay care for patients, many of whom had to wait far too long. Imagine proposing a solution to your boss (offering to work for half-pay so he could afford to have you work twice as many hours to increase ER physician staffing) and being told flat-out “no.”
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