The Police State We Call Health Care

Ameer Hassoun

I have some news for you. We are living in a police state! I am sorry, as I know it hurts to hear that we choose to live in bondage.

Don’t be fooled by shiny title of being a health care professional, the pennies on the dollar we get paid from the ridiculous pool of money we generate, and the lifestyle that we were promised but rarely experience.

We are watched 24/7 because of the title we carry. We are judged for every word we say, whether at work or outside work. We are evaluated by students, patients, residents, co-workers and supervisors. I have not seen any evaluation for a patient, many of whom should be charged with some extra payment for abusing the system or the team. And the residents we can evaluate are protected by a system called ACGME, who might retaliate by giving a bad score for the training program if that program did not crucify us. We became hostages by our own doing.

Your life outside work is not yours to control. Your Facebook and Twitter accounts are watched. You will be judged for the opinions you express. And sure enough you might even be disregarded for some promotion because of your beliefs, practices or orientation. The stigma of being from this race, a graduate of this institution, having this sexual orientation, being from this background or finishing at a foreign school is alive and thriving behind closed doors. Let’s be honest about it.

I have seen it around me happening in the past. You have to join a crowd, but which crowd? The oppressors? The oppressed? It cannot be both. The academics of medicine also is infected with this disease. You have to be from a certain closed circle to rise. You have to compromise your righteous path in order to gain.

You cannot call in sick. You must sacrifice your personal life. You need to go “above and beyond,” simply because that is expected. We are the victims and the criminals at the same time.

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Heaven forbid you give feedback to a resident who felt it was harsh (despite his or her limited knowledge). We avoid consulting services daily, because we do not want to deal with the frustrations. I have seen how residents from surgery or orthopedics can be dismissive of your concerns, how they can delay care for hours, and how they can request unnecessary studies before even seeing the patient. And if you become forceful about timely evaluation or treatment, trust me – you will hear about it later. Who is suffering here? I think patients and the emergency team equally.

We spend a significant amount of our time addressing nonsense scenarios. We are fostering this culture, because we accept it. I see myself drifting every day into accepting this wrongdoing by people around me. I cannot blame a patient or the family if our own team members are not functioning as they are supposed to.

Recently, I had a very nice chat about this culture with a brilliant pediatric surgeon who recognized how it limits our ability to provide excellent and efficient care. We reached a realization that our culture need to be changed. This change will be a long road filled with many hardships.

We have to stop judging others. We have to quit the hierarchy. We have to eliminate the unnecessary hoops that we have to jump through. We need a system that cares about patients more than the bottom line.  We have to create a system that holds health care professionals and patients equally accountable. And most importantly, we need to eliminate this notion that we are an industry. I might be a dreamer in this police state called health care.

What do you think about this topic? Please share your experiences and thoughts.

Our Rights and Obligations

Ameer Hassoun

In 2012, after only a few months of my taking my new position, Hurricane Sandy was heading to the Northeast. My passion for disaster relief kicked in.  After all, I have seen many wars during my childhood which led in part to my decision to become a pediatric emergency doctor.  I have always desired to help those who are in need and to rescue the disadvantaged. I found in Hurricane Sandy an opportunity to satisfy my goals of helping families suffering from displacement and hunger. Despite my working an 18-hour shift so that colleagues would not have to travel during the hurricane, I enthusiastically jumped into the relief work to help families in Far Rockaway.

I met an energetic nurse at my institution and offered to help these families with him on my days off. We managed to gather a group of health professionals and went to the devastated areas where we witnessed the destruction and the agony of that community. I could not believe that I was in a major metropolitan area in the U.S. There was no command center arranging volunteers’ work.  There were so many volunteers, but a minimal ability to utilize them efficiently. I sat at an emergency clinic that was assembled in a school, surrounded by large amounts of medications that were about to expire. I didn’t see more than four patients in my ten hours there because few people in the community knew we were even there.

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When a disaster hits, many physicians would like to go to the front line to help those who are in need. We take the extra steps necessary, but our efforts are shattered once we face the disorganization on the ground. I couldn’t believe that I was in the United States! And in one of the biggest cities in the world! Food and clothing is what mattered the most to the affected communities during the cold days of November. Lack of electricity and communications made our efforts patchy and ineffective. This situation continued for weeks.  In an environment lacking critical resources, like electricity and water, I came to learn that my emergency relief work would be held to the same legal standards of care as those to which I am held at my hospital. This was because I was a paid employee. Had I known this before volunteering, I could have been discouraged from doing so. Our system is crippled by laws that do not protect healthcare professionals donating their time and effort to help in disasters, where a quick response time is critical. Unless it is your job or you happen to be at the site when the disaster takes place, you are just as liable for every patient you see as you would be at your hospital, despite your working under suboptimal conditions. In other words, patients you treat might sue you regardless of how terrible the conditions were or how underequipped you were.

The US immunity laws applicable to physicians are a patchwork with too many gaps and inconsistencies. No law of which I am aware comprehensively addresses liability and immunity issues for physicians responding to disasters. Only unpaid volunteers and government workers are protected. And the rest of us who are not under such protection might suffer. The rule that “no good deed goes unpunished” should not be the norm!

How do you feel about this topic? Please share your thoughts

Here Is My Notice. I Quit!

Ameer Hassoun  Recently, a friend approached me to discuss his career options after his first job. He started by explaining the main reasons why he is quitting and looking for an alternative job. He worked at a private setup in a small town. He had a boss who did not provide what was necessary to improve his productivity. And finally, he did not get the bonus he was promised as his RVUs came $200 short. It was clear to me why he needed to find another job, and sure enough, he landed at a better deal a few weeks later.

A few months earlier I had gone through a similar experience of switching jobs. While there were many reasons to make the switch, the most important one was my time-consuming daily commute. This, combined with the threat of workplace violence and the lack of a work-life balance, made it easier to pull the plug.

A few months before that, another friend called me as he was thinking of quitting his job at a fine institution because he was overworked, underappreciated and his boss was making it difficult to climb the ladder.

Another brilliant physician I know recently decided to quit his academic job because he could not afford to keep up with his loans, taxes and other expenses, ending each year at the same point he started. While he loves academia, he could not continue the bleeding and not saving for the future.

These examples share a common thread – mismanagement.

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Many administrators complain of high physician turnover. They are not evaluating the reasons why people quit. The majority of pediatricians and PEM physicians do not worry as much about compensation as other specialties. If our jobs support growth in our careers, create an acceptable work-life balance and do not limit our creativity with red tape, why would we quit?

Leaders should lead by example and not by giving orders.

When you see your boss disconnected from the clinical reality of the job, but trying to micromanage you, you will leave!

When you feel that you have been overworked because you are an excellent worker while others are not being stretched as thin as you are, you will leave!

When you see that your personal life is going down the drain because of your schedule and responsibilities without appropriate protection of your own time, you will leave!

When someone hired after you with less experience gets promoted and your work is underappreciated, you will leave!

I asked my father, a Berkeley graduate physicist, if job conditions in America during the Sixties were similar to now (that is, deals behind closed doors, with jobs and promotion dependent on who you know rather than what you bring to the table). His answer was “no.”

Physicians should think carefully about all of these aspects prior to switching jobs. They should ask why they have an empty position at this institution? Why have other physicians left? And most of all, is their position a match for what they are looking for? Try connecting with people who have left and ask them, they can provide a valuable insight.

The bottom-line is: Choose your boss and setting wisely, as it can make your career or break it!

The Troubled Winter

Ameer Hassoun

Winter is coming! Is it just the ominous motto of House Stark in the famous HBO show Game of Thrones? I think it should be our warning motto in Pediatric Emergency Medicine.

It is the season of long wait times, the influx of unprecedented numbers of patients, the wonderful bronchiolitis, the respiratory viruses that would bring every patient possible with asthma exacerbation, the holidays that bring with it the upset stomach and gastroenteritis.

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Many emergency rooms around the country are staffed and supplied according to costs rather than needs. This will lead to understaffing and and create terrible conditions for patients and healthcare workers. The puzzling part is that no one can predict what can walk through the ER door. We All think that we can handle it, we push patients in, place them in chairs and stretchers across the hallways, then the reality hits us! Patients are not triaged or registered, vital signs are not recorded and nurses are not available to evaluate or give medications. This constant stress for patients and staff comes with Winter. Is it poor planning? Is it the lack of enough staffing? Is it the roadblocks that the system created? We are forced to change our practice and alter our standard of care by discharging patients without being properly triaged or not giving medications and relying on prescriptions that patients may not even fill. These practices may put us at a higher risk of committing an error and lower patient’s satisfaction. But what worries me the most is discharging a patient who should have been evaluated further, because we are crossing these checks that may prevent us from committing such mistakes.

How can we solve this chronic problem? Is it the institutional policies? Is it the chronic lack of staffing? Is it just a financial issue? Or is it just bad planning? A quick PubMed search showed a very limited amount of information available in this field. One study from Australia concluded that some conditions (Croup, Bronchiolitis, diarrheal diseases) do have seasonal variations. Another suggested providing staffing and space during these months did improve the throughput at their Pediatric Emergency Department.

I hope one day similar plans are implemented across the country to improve the overall patient conditions and reduce healthcare workers strain.  Can we see that coming? Not sure if that will happen soon enough.

What do you think about this topic? Please share your thoughts or institutional experience in tackling this issue.

Are We Killing Our Profession in The Era of ACGME Regulations?

Ameer Hassoun

A decade ago when I started my medical training, we celebrated, as residents, the impact of duty-hours regulations on our daily lives. We were the first generation to experience the winds of change. This change was prompted by the famous case of Libby Zion in my home state of New York. The death of this young girl lead to an unprecedented ripple that changed the world of medical training in the United States.

Since then the Accreditation Council for Graduate Medical Education (ACGME) implemented rules and regulations to limit residents’ fatigue and work hours. This was an important step to help create checks and balances to limit the overdependence on trainees.

While I am a big advocate of such regulations, I have seen residents and fellows gradually drift from the core of what our profession is all about – patient care.  In the past few years, after I started my job as an attending physician, I noticed some residents limiting their productivity so that they won’t be “overworked.” Some residents and fellows became apathetic regarding care for patients in the last hour of their shift, because they wanted to leave on time. I even had a trainee who left me with a patient who was having an acute stroke, because it was time to go home! On the other hand, program directors and administrators are fostering such approach due to fears of ACGME and RRC citations. Are we creating a generation of physicians who are apathetic, less invested, and more self-centered? Let’s not forget that with such regulations they are less exposed to pathologies that they will have to take care of in a few years’ time.

Recently, the Journal of Graduate Medical Education (the official journal of ACGME) published a meta analysis that concluded that “duty hours alone has not resulted in improvements in patient care or resident well-being. The added duty hour restrictions implemented in 2011 appear to have had an unintended negative impact on resident education.”

We as attending physicians took the burden without any regulations or limitations. We as supervisors will be blamed if we instructed our trainee to stay a bit longer to learn from the case they are working on. I think such rules restrict attending physicians and prevent them from teaching appropriate compassion and care. I am not claiming that all attending physicians are the same. There are some who just want to keep trainees for service reasons, and we need some form of protection against that. The analysis also recommended seeking new approaches to the issue of physician fatigue and its relationship to patient care and resident education.

The balance between training, education, experience and work hours needs to be revisited, so that we don’t lose what our profession is all about – patient care!

How do you feel about this topic? Please share your comments and experiences.