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Still More ER Questions
Part 2

Rookie docs killing patients
Dumb docs killing even more patients
Spreading germs
The glamour of an ER career:  the pay, the babes, the title, the job security, and miscellaneous accouterments
Why the pay is deceptive
The sacrifices docs make on the way to the Yellow Brick Road
The one night I said to heck with medical school
"Hard working Americans"
Does the thrill ever go away?
Why malpractice verdicts are often just a crapshoot
Faking malpractice for fun & profit (mainly profit)
My prediction:  some doc will "go postal" on an attorney
A proposal to eliminate frivolous malpractice suits
Teachers work as hard as ER doctors?  Is this politically correct rhetoric or a hallucination?
How the practice of emergency medicine can be nightmarishly difficult and risky
Docs aren't the only ones making mistakes
Sleep deprivation

Q:  Dear Dr. Pezzi,

I greatly enjoyed reading your site.

Do you believe that your knowledge and experience makes a significant difference in the cases you handle?  That is, do you really believe you could have saved patients that died on you a decade ago with the experience you have now?

A:  Yes, I do.  Offhand, I can think of just one patient who is in the grave now because he had the misfortune to see me when I was a rookie instead of seeing me when I was experienced, but there are probably a few more.

Q:  Do lesser doctors really kill dozens of their patients?

A:  Unquestionably.  I know some ER docs who kill so many people that it makes me wonder if they're getting kickbacks from the local mortician.  Incidentally, anyone who is counting on lawyers and our malpractice system to root out those quacks is going to be disappointed . . . or dead.  Those guys were such smooth actors with pleasant personalities, and their personas and looks were so stereotypically doctor-like, that they were rarely or never sued.  Americans are enamored with appearance.  That's why we elect handsome, distinguished-looking politicians who are airheads.  That's why women long for attractive studs, even if they're abusive or addicted.  That's why men lust after babes, even if they're vacuous.  That's why we tune into television shows hosted by people chosen on the basis of their looks, not brains.  That's why I can't think of one Hollywood actor or actress who is ugly; it's as if directors think that only beautiful people are talented.  That's why I don't believe the producers of The Bachelor when they parade out 26 beautiful people, but say that their selection was influenced more by sincerity than appearance.  That's why Robert Young, the actor who portrayed Marcus Welby, MD (the all-time stereotypical image of a doctor), probably could have practiced medicine in real life and never been sued even though he was not a physician.  If you think I'm exaggerating, you don't know the case of Gerald Barnes, who wasn't a doc, but posed as one for many years.  He would probably still be practicing today if he had not been turned in by a co-worker.  But his patients?  He hoodwinked all of them.  Why was he so successful?  Because his appearance was the epitome of a doctor:  he appeared like what people think a doctor should look like.  In contrast, when I'd pop into a patient's room, the first thing they would often do was question my qualifications.  "You're ... a ... doctor?  I thought you were a high school student!"  Perhaps it was the zits that still crop up every now and then, my impish grin, or the teddy bear in my pocket.  Who knows?

Seguing on to another subject:  germ transfer.

Q:  Does it REALLY matter if you wash your hands?

A:  Yes.  It's been scientifically proven.  Hence, I'd wash my hands 40 times per day in the ER, I'd disinfect my stethoscope, penlight, pen . . . you name it.

Q:  For that matter, why do surgeons "scrub in" when they are going to wear gloves anyway?

A:  In case a glove breaks.

Now, on to the juicy stuff . . . .

Q:  Your site makes medicine seem FAR more glamorous and exciting than it seemed to before — which doesn't seem to have been the intention.

A:  Believe me, it wasn't.

Q:  . . . you reveal a very exciting, intense world.  Med school seems like a tough mental contest rather than merely a regurgitation machine fair.  The pay is more than twice what any other profession makes, and it starts out high immediately after graduation.  You mention perks:  no speeding tickets, the title, the A-list women, cops beating up people who assault you, nearly lifetime employment, no trouble finding jobs . . . basically, doing work that matters to society and being recognized for it.

A:  Perhaps it's not as bad as I made it out to be.  Perhaps I just have a terminal case of thinking that the grass is greener on the other side of the hill.  However, I'd like to comment on some of your statements, leading off with a subject that I can't resist:

The A-list women:  If you've seen my picture, you probably wonder what the heck I'm doing cavorting around with A-list women.  In any case, such opportunities gave me the chance to see what such women have to offer, besides their silky hair, beautiful faces, mesmerizing smiles, seductive glances, and bodies that'd make Hugh Hefner drool.  So what do such women have to offer?  Generally, not much.  Except for one woman who looked like a model and had a brain like a rocket scientist, the others were noticeably less engaging.  Downright boring, in fact, in some cases.  It's truly amazing how testosterone increases the tolerance for stupidity.  A couple others weren't ditsy, but their behavior prompted me to think, "You mean you've acted this way your entire adult life and no man ever told you what a prima donna you are?"  Can you tell that my interactions with those women left me a tad disappointed?  However, unlike Donald Trump, I learned my lesson.  My criteria changed, and instead of looking for a "9" or "10," I wanted a woman who is down-to-earth, slim, reasonably attractive (or even just plain), interesting, and SMART who doesn’t smoke, use drugs, or sleep around. OK, I was redundant.

The pay:  Ah yes, the fabled wealth of doctors.  Thanks to the persistence of that myth, I was able to have a far more exciting social life than I would have otherwise had.  Granted, doctors are not paupers, but you should put their income into perspective.  Let's say that a person goes to college and medical school.  That's not just eight years without pay, that's eight years of getting deep in debt (unless that person has rich parents).  Then comes the residency years, when pay is just enough to live on.  I was paid about $22,000 per year, but I had to begin repaying my loans, so I was always broke.  Residents make more now, but they're even poorer than I was, thanks to inflation, higher taxes, and phenomenally larger loans.  Let's say a doc is financially frugal, so he decides to postpone living the good life until his loans are paid off.  That could easily take a few more years.  So when is that big, fat paycheck really his (or her) money?  Let's add this up:  4 years college + 4 years medical school + 3 years residency (or sometimes another 4 or 5) + 3 years paying off the loans.  That's anywhere from 14 to 19 years until your bank account just begins to creep above zero.  If you think that's depressing, consider this:  in that 14- to 19-year period, you've worked as many hours as most people do in their entire lives.  Then you can begin socking away the money, and listening to people bellyache about how much money doctors make.  Conveniently, they ignore the years of preceding poverty, and the tremendous sacrifice it took to achieve that earning power.

I don't think most people have any conception of the hardships that doctors face during their training.  I once went an entire summer without being in the sun, because I arrived at the hospital before sunrise and left after sunset 7 days per week (except when I was on-call, when I never left).  I am not a depressed person, but that experience made me melancholic.  I felt so detached from nature — not in a tree-hugging sort of way, but in a "Dammit, I'm human, too, and I have things I'd like to do besides work 115 hours per week."  My family and friends became virtual strangers to me, cloistered as I was in the dark corridors of hospitals, treating an unending series of patients.  Holidays?  What holidays?  Christmas Eve, Christmas Day, New Year's Eve, New Year's Day, Memorial Day, Labor Day, the Fourth of July, Valentine's Day, Thanksgiving . . . patients get sick on those days, too, so we worked 'em.

The early adult years are often viewed by people as some of the best years of their lives — or so I've heard.  For me, they were torture.  Yes, I was a supremely dedicated student, but I wasn't a robot.  Perhaps I was too dedicated, and should have blown off some of my responsibilities.  However, being a conscientious person, that was almost impossible for me to do.  The only time I recall doing it was one night in which I said to heck with medical school, and I spent an hour trying to make love to my virginal girlfriend, whose vagina was so tight that entry was impossible.  I then spent the next eight hours trying a different tack, thinking that protracted foreplay would permit entry.  No such luck.

I arrived at school the next day an hour late, without a whit of sleep, with a tongue and lips so sore from exertion that I could not enunciate correctly.  Coupled with the red abrasion around my mouth, it was no wonder that my classmates raised a few eyebrows.  I looked and felt like a clown, but what really bothered me was the realization that I'd missed an hour of class.  Had I missed something?  The perennial fear of medical students.

Oh, yes, the pay, and those 14 to 19 years after high school that it took to pocket a dollar that was really mine.  Let's say that instead of going to school, I went to work and made $40,000 per year.  That isn't a stretch, because anyone smart enough to be a doctor could easily make that much.  In 14 to 19 years, I could have made $560,000 to $760,000.  Now let's be a bit more realistic.  Toward the end of my mowing career, I made $35 per hour.  Accounting for inflation and higher taxes, that's probably equivalent to $70 per hour in today's dollars.  Now, instead of talking a measly half-million or so, it's a couple of million dollars that I passed up before I had a dollar I could call my own.  Could I ever catch up to the earnings I would have made, had I followed the other path?  Not on the salary of an ER doctor.  So, from a financial standpoint, what I did was idiotic.

Because of the protracted education of physicians, their earning years are compressed into a much smaller window of time.  Our tax laws make no provision for this, and the minute a doc starts making the big bucks (and even before his loans are paid off), he must listen to politicians espouse tax cuts only for the "hard working Americans."  If you'd worked as hard in your job as physicians have worked to become licensed practitioners, you'd be downright resentful if some twit got in your face and insinuated that you were not hard-working just because you made more than $50,000 to $70,000 — which, according to assessments made by various economists, seems to be the dividing line that defines who is, and who is not, hard working in the eyes of the politicians who favor this "hard working" prattle.  Make less than that, and you're "hard working."  Make more, and you're someone the politicians want to penalize with higher taxes.  I'd love to hear Senator Tom Daschle, one of the foremost proponents of this, logically explain how a man can be hard-working if he makes $45,000 per year, but if he gets another job or busts his butt for years to obtain an education so he can make even more, he is no longer "hard working."  Obviously, his rhetoric is illogical, divisive, contradictory, and damned insulting for people who work not just hard, but exceptionally hard.  Daschle, you're an asshole, and as an American (and a hard-working one at that), it's disheartening to think that someone like you can be paid by the taxpayers for pitting one group of Americans against another.  At a time when we should marshal all our resources and energy into the war on terrorism, you're making a career out of bashing the very people who pay your salary.  You contemptible nitwit.

By the time you're a physician, Daschle will be long gone.  However, he will be replaced by other politicians who wish to capitalize on this divisive ruse.  Hence, for the foreseeable future, you will have to listen to unprincipled politicians indirectly denigrate your hard work.  However, there is good news in sight.  Given that medicine in America is increasingly socialized, and given that the politicians control the purse strings, and given that few doctors have the balls to fight back, politicians are slowly but surely eroding the incomes of doctors.  The good news?  When you're a doc, you just might be a hard working American!

Finally, you should realize that few physicians work 40-hour weeks.  Even after their arduous training period, a 40-hour week is just a pipe dream.  There is paperwork, dictations, continuing education, self-study, interfacing with insurance companies, bureaucrats, lawyers, judges, hospital administrators, conferences, meetings, meetings, and more meetings.  If you want to look at just the hours you're paid, yes, you might "work" 40 hours per week.  However, if you want to keep your job, you'll have to work another 15 to 20 hours without pay.  I think most hard working Americans would scream if they had to work 15 to 20 hours per week without pay.  Time and a half?  Double time on holidays?  Forget it!  You're a doctor!  For such overtime, you don't receive a penny.  One of the perks of being a doc, you know.

As if that isn't bad enough, many of your work and "unpaid work" hours will occur at abominable times and in abhorrent circumstances.  You might get off work at 7 in the morning and be expected to return at noon for a department meeting lasting one to three hours, then return at 7 PM for another night shift.  I can't think of another profession that routinely makes such insane demands on its members, especially considering that being alert can make the difference between life and death for a doctor's patients.  Can you imagine the uproar in Congress if airline pilots were forced to do this during the night before a flight?  If he chooses, a pilot can switch on the autopilot or have the co-pilot take over.  I wish I could have done that in the ER!  In theory, the reason why pilot work hours are so restricted is because they have a job in which alertness is critical (e.g., the October 28, 2002 edition of Time magazine reported that pilots for United Airlines work about 50 hours in a busy month).  However, alertness is equally critical for doctors.  It isn't very often that a pilot has adrenaline surging through his veins as he dodges one aircraft after another or tries to compensate for other disasters.  In contrast, an ER doc can be in adrenaline overdrive from the minute he steps in the ER until three hours after his shift is over (because that is how long it may take to complete patient care).  I've flown a plane before, and so have many of my ER colleagues.  One of the reasons why it is so enjoyable is because it's a fun, comparatively easy, relaxing activity.  If it were anywhere near as tough as working in the ER, we'd get our jollies some other way.  Since it is far more draining to be an ER doc than a pilot, if pilot hours are restricted, the same should be true for ER physicians.  Humans are well-adapted to dealing with episodic stress, such as a pilot managing a windy landing, a cop in a high-speed chase, or a caveman running from a predator.  In a busy ER, the stress goes on, and on, and on.  It's grueling.

Oh, but that's just the quotidian torture that docs must accept.  Then there are the gotchas that are more rare, but far more devastating.  Imagine that it's Christmas Day and you're lucky enough to have that day off.  You're having a great time with your wife and family.  You're greeting friends and relatives who stop by for a visit.  Then there is another knock on your door.  A family member?  Santa Claus?  Even a door-to-door salesman or religious crusader?  No such luck.  You're being sued.

When doctors are served with papers informing them of a lawsuit, the timing of the notification is often purposely chosen so as to inflict the greatest possible psychological damage.  Many attorneys don't give a hoot whether or not any medical error was made; if they think they can conjure up some legal rhetoric that scares the doc's insurance company into an out-of-court settlement, they'll do it.  To heighten their chance of success, they don't just sue you, they do so in the most venomous way they can.  They twist the facts, distort the truth, and lie through their teeth.  They try to pummel your psyche, and make you eager to cry uncle even if you know you did nothing wrong; you just want the nightmare to stop.  The more principled attorneys just limit themselves to presenting specious claims.

Unlike some people, I don't try to hide my mistakes.  I'm probably the only doctor in the world who so openly discusses them.  Remember that patient I thought I killed when I was a rookie?  Rather that keeping mum about it (as docs are taught to do), I called the patient's wife, and in a long conversation, told her that I thought I'd screwed up, and that I felt rotten about it.  And I did.  I literally felt as if I'd been punched in the gut, and that feeling took weeks to dissipate.  Even now, years later, it still pains me to think that someone might be alive, had I done a better job.  I'm not comforted by the fact that I probably killed less patients than an average ER doc, and certainly fewer patients than some of my colleagues who had a knack for turning people into corpses.  I have my own standards of perfection, and "almost perfect" is far from perfect, if you're dealing with people's lives.

Considering the foregoing, there is no attorney who can punish me more than I'd punish myself — if I truly made a mistake.  If I screwed up, I'll be the first one to admit it, and I'll punish myself for it until the day I die.  However, a distressing number of lawsuits these days are utterly frivolous (here's an example of one), and that is what is so reprehensible.  Furthermore, even in cases in which an ER doctor makes a mistake, the blame should not be shouldered solely by him.  Many of these errors occur because the ER is just too busy, and the doctor's time is stretched so thin that he either must cut corners, or choose to delay the care of some patients so he can better treat the ones he is already caring for.  Either way, someone may die, and someone may sue.  This is a terrible position to put any doctor in, and it is one of the reasons why I think anyone who goes into emergency medicine must be a masochist or blindly optimistic.  If you're an ER doc, at times you will be flooded with more patients than you can optimally care for.  This happens infrequently in well-staffed ERs, and routinely in other emergency departments.  At one very busy ER in which I was the sole doc working the night shift, I used to beg my boss to increase staffing.  I offered to work for half my salary so he could afford to hire another doc.  Two docs working for half pay . . . he wouldn't pay any more, so what's wrong with that?  I don't know, but he said no.  I think he couldn't find another doc willing to take a 50% pay cut.  It's not that I don't like money.  I do, but I'm even more concerned with doing everything I can to ensure that my patients receive the best possible care.  Sometimes an assembly line approach isn't good enough.  Sometimes I need more than ten minutes to save your life.  If you need more and I don't have that time because I must give it to someone else, you may die.

The title:  Yup, I'm a doctor.  I can present myself as a doc to the world and not get arrested.  Trouble is, so can lots of other people who aren't MDs.  Dentists, optometrists, chiropractors, naturopaths, podiatrists, psychologists, and sexologists can all obtain a doctorate degree with far less blood, sweat, and tears than it takes to make it through medical school and residency.  I have some friends who followed those career paths, and they've shown and described for me what it took to get there.  Dentistry is the toughest of them, but still a virtual vacation compared to what MDs go through.  One of my friends is wrapping up her optometric education, and she admitted that there is only so much to know about the eyeball and vision.  Mastering that limited subject leaves plenty of time for living a normal life.  I wish I could focus on one frigging part of the body.  Teeth.  Eyeballs.  Feet.  The spine.  Your neuroses.  Your sex life.  Sheesh!  A walk in the park!  Instead, I must know about everything from dandruff to what to do if you come in with a spear through your heart.  I have to be an expert in managing countless thousands of scenarios in pediatrics, neurology, surgery, internal medicine, cardiology, orthopedics, psychiatry, plastic surgery, gastroenterology, dermatology, hematology, obstetrics, gynecology, rheumatology, radiology, ophthalmology, oncology, immunology, urology, anesthesiology, pathology, and otolaryngology.  After all that, my title — doctor — is no more exalted than that of a sexologist who obtained his doctorate in a few months time from a diploma mill that would give a Ph.D. to anyone with a pulse and a pile of cash.

Ultimately for me, being a doc isn't about the title, money, or chasing A-list women, or having cops beat the crap out of my enemies because they hope that if they catch a bullet some day, I'd pull out all the stops and save them from an early death.  Being a doctor is about sacrifice.  You'll sacrifice a good chunk of your life just to get your own scalpel or prescription pad, and once you're there, the sacrifice continues.  Weekends with your patients, not family.  Holidays?  Ditto.  Nights?  More patients, instead of seducing another A-list babe.

Q:  One thing that especially appealed to me is the "fire through your veins," or adrenaline rush.  You said that an ER doctor can enjoy shots of this for his entire career.

A:  Did I say enjoy?

Q:  But does the same stimuli become less exciting and just plain stressful?

A:  Yes, it does.  When you're a medical student, intern, resident, nurse, or just a person watching a medical show on television, codes and other dramatic events are exciting and even fun.  I've seen med students look happier racing toward a code than some kids do on Christmas morning racing for the presents.  However, when you're an attending, the man in charge, and the person ultimately responsible for someone's life, things aren't such a blast.  If you screw up, someone can die.  If you don't screw up, someone can die.  And they frequently will.  After all, this is an emergency room, not Romper Room.  People come into the ER with knives in their chest or neck, burned to a crisp, with part of their head blown off, or just having a heart attack.  Such critical patients arrive sometimes just once per shift, and other times every few minutes.  I once went about a year and a half without any patient dying in the ER.  Considering the bad protoplasm I was given to work with, I think that was pretty remarkable.  Maybe it was a fluke, but then maybe Joe DiMaggio's 56-game hitting streak was just a fluke, too.  Who knows?  Who cares?

I care.  I went into ER because I wanted to save lives, not pat myself on the back because I did my best and really tried.  If I really try and someone dies, he's still dead.  I was lucky in that I never lost a young patient who wasn't deader than a door nail when he arrived at the ER.  Had I lost a potentially salvable young patient, it would have rattled me.  I'll  never forget one evening.  I was working the afternoon shift, so I had another doc working with me.  A drunk driver hit two teenagers, and they ended up in our ER.  My patient had been plastered onto the front of a pickup truck, then carried for a couple of miles as the boozer decided what to do with his new hood ornament.  Eventually he stopped, and my patient slumped to the ground.  The paramedics handed me a brain-dead patient, while my partner received an alert, talkative kid with a rapid pulse.  He was in shock due to blood loss.  Treating such patients is straightforward:  give fluids, blood, oxygen, stop the bleeding, do surgery if you have to.  It's not rocket science.  Hence, when I found out a few hours later about that patient's death, I was surprised.  Saving trauma victims in shock is one of the great successes of emergency medicine, especially when the patients are promptly taken to an ER, as that patient was.

I can't recall how we divvied up the patients when two presented at the same time to the Trauma Room.  Why did I take the brain dead patient, and my partner take the awake, talkative kid?  I'm not sure.  I can recall trivial details on cases that occurred over a decade ago, but the decision about who took what patient that day totally escapes me.  Perhaps it was because I was more experienced, and when we entered the room, it seemed as if my patient needed more intensive therapy.  Indeed, we opened his chest, performed direct cardiac massage, clamped his descending aorta, and in general pulled out all the stops.  Emergency thoracotomies are impressive operations, and even jaded, experienced ER nurses perk up when we do one.  Had I know that my patient was a goner, and my partner's patient had a decent chance of living, I would have taken that patient, and probably saved him.  My track record on saving talking patients in shock was 100%, even when they were old folks with limited cardiovascular reserves.  Saving such a person in the prime of his life?  Much easier.

I could have told my partner, "This kid's a goner.  You take him, and I'll take the chatterbox over there."  But I never imagined that my partner couldn't stabilize such a patient.  Or why didn't he ask for my help?  Or why didn't the nurses come get me?  "Dr. Pezzi, that patient is crashing.  We need you back in the Trauma Room."  I was in the cardiac area taking care of a bubblegum-chewing 20-year-old woman doing her best to convince me that she had really bad chest pain.  I found that difficult to believe, considering that she was smiling, laughing, and making out with her boyfriend every time I'd pause to scribble a few notes on her chart.  Yes, it's her God-given right as an American to come to the ER for anything from a loose vagina to a preposterous case of chest pain, and most people fail to see the harm in such questionable visits.  I don't.  They divert time away from patients who really need us.  In this case, had I not seen that young lady, and had I not seen a kid with a week-old rash and a few more such trivial problems, I would have been in the Trauma Room.  And, dang it, I would have saved his life.  He might be reading this now, telling his buddies, "See this whacked-out doctor who complains about dating A-list women?  He saved my life ten years ago."

Q:  Does it ever get to the point when you're like "multiple gunshot wounds . . . guess I'll miss the golf tournament."

A:  Had I missed a golf tournament, that would be a blessing.  Watching others golf is, for me, about as fun as watching others read.  For reasons I still can't fathom, a local car dealer took a liking to me and gave me all sorts of presents, from free use of a car, to expensive lawn furniture, to tickets to the Buick Open.  I gave the tickets to someone who liked golf.

Q:  What would happen if judges started rejecting most frivolous suits?

A:  What if Shannon from the original The Bachelor mini-series began begging me to date her?  What if the state of Michigan kept pestering me to pick up the check for an unclaimed lottery prize, just so they could balance their books?

Have you been smoking something?  Do you honestly believe that will ever happen?  Didn't any professor ever tell you that rhetorical questions are more effective when they're rooted in reality?

Have you ever heard of a judge who was a doctor, not a lawyer?  The fact that 100% of them are JDs, not MDs, colors their judgement.  I would not call it collusion, but asking a bunch of lawyers to give a fair shake to a doctor is like asking a bunch of white men in the old South to give a fair trial to a black man.

Think I'm exaggerating?  I'm not.  This is why I'm dead serious when I say that anyone who wants to be a doctor is either nuts, a masochist, a gambler, or perennially imbued with a "it won't happen to me" mentality.  I once believed that our justice system was fair and that innocent people had nothing to fear.  I also once believed the fairy tales my Mom read to me when I was three years old.  Let me preface what I'm about to say next by stating that I agree that people should have a right to sue a doctor if he makes a mistake and they suffer an adverse result.  That's how the malpractice laws are written.  If a doc screws up and you're not harmed, you should have no reason to sue.  If the doctor does not screw up, and you suffer an adverse result, you should have no reason to sue.  After all, everyone eventually dies, and you can't blame doctors for that.  Remember the ulcer that my doctor misdiagnosed as a back problem, for which he—ha, ha—prescribed a 4-millimeter shoe lift?  A shoe lift for an ulcer?  That's an open and shut case of malpractice.  He screwed up, I suffered.  Nevertheless, the thought of suing him never entered my mind.  That was back in the old days when people didn't jump for joy when something bad happened to them which gave them reason to sue and the chance to be an instant millionaire.  Now, some people are so eager for instant riches that they don't wait for someone to screw up, they go out and manufacture evidence to make it appear that way.  A decade or so ago, there was a rash of people alleging they found various things in soft drink bottles.  As luck would have it, a couple of dudes came to my ER, complaining of a used condom in a bottle of Mountain Dew®.  These guys, who we'd now call Dumb and Dumber, eventually let it slip that they were responsible for inserting the condom, thus blowing their dreams of winning the Scumbag Lottery.  I had other cases, too, one of which involved me.  Here is that story:

It was about 1 a.m. as I was driving home from the ER. I had been traveling about 25 mph through town, but was slowing down for an intersection just ahead. I noticed an 18- to 20-year-old man, who had been sitting on the curb, suddenly get up and rapidly sprint toward the driver’s side of my vehicle. I swerved to the right and he missed his intended target.

For a split second I wondered what the heck he was doing. Then it hit me. Clearly, he wanted to run into the side of my car. He was either insane, on drugs, or hoping to make money the old-fashioned American way—by suing someone. "Yes, Mr. and Mrs. Jury Members, I was just minding my own business when this driver hit me with his car. Since then, I’ve been in horrible pain and I haven’t been able to have sex with my 14-year-old cousin—uh, excuse me, my life hasn’t been the same. Now wouldn’t you like to give me a million dollars?"

Saying that I was angry about what he was trying to do is an understatement. I wasn’t angry, I was pissed. Had he succeeded in hitting the car, he would be the victim, and I would be the defendant.

These staged accidents are far more common than you might imagine, and they cost Americans billions of dollars every year. The profit potential for such cases has not escaped the notice of personal injury attorneys, some of whom serve as the ringleaders for the arranged "accidents." The attorneys recruit unethical doctors to falsely testify about the patient’s injuries. For giving this warped testimony, the doctors are handsomely paid.

Staged "malpractice" is increasingly common, too. I’m not going to present a how-to manual on faking malpractice, but it is easy to do. Not surprisingly, this subject is intensely interesting to personal injury attorneys, most of whom are deeply disappointed that physicians do not commit genuine malpractice on a more frequent basis. Years ago, I contacted a number of such attorneys, offering to sell them a grossly overpriced "how to fake malpractice" manual. They didn’t bat an eye at my price; they wanted it. Of course, when you look at the size of the awards being dished out by juries, it could have been a wise investment. Naturally, I did this only as a test and I refused to sell the manual. It was only a test, but they flunked it. And you wonder why I hate attorneys as I do?

I heard about a case in which a patient inserted a surgical needle into a wound to make it appear as if the doc left it there.  That person would probably now be driving around in a Rolls-Royce had he not been dumb enough to insert a needle used only in veterinary medicine.  If you wish to upgrade your financial status and not bother with the daunting odds of the multi-state lotteries, here's an easy way to do it.  1. Have Doctor A suture a cut.  2. Go home and find a twig.  3. Insert said twig into said cut.  4. Wait a few days until it becomes horribly infected.  5. See Doctor B, who will open the wound and discover the twig.  6. Watch the late-night television commercials to obtain the toll-free number for the most bombastic personal injury lawyer you can find.  7. Said lawyer will pound his chest, relish the chance to employ his most vituperative legal lingo, and recruit Doctor B to testify.  8. Doctor B will feel like a hero, and gleefully comply.  9. Doctor A's insurance company will be spooked, and meekly ask the personal injury lawyer, "How many zeros do you want in your check?  Five or six?"  10. The lawyer will be so happy he'll send his wife on a shopping spree at the nearest jewelry store.  The patient will be happy, his banker will be happy, Doctor B will be happy, and they will all live happily ever after.  Or will they?  What might mar this perfect fairy tale?  A righteously incensed Doctor A, that's who.  Granted, the average doctor is a spineless, self-deprecating wimp who will, on command, put his tail between his legs and slink off into the sunset without so much as a whimper.  But that is just because the doc fears the consequences of retaliating, as he should do, if we lived in a perfect world in which every injustice is met with justice.

Sooner or later, here is what I think will happen.  A doctor with some terminal illness and a few months to live will be sitting on his porch, reflecting on his life.  His first kiss.  His hopes and dreams.  His wife.  His kids, and how they were cheated out of their inheritance by a patient who concocted some frivolous lawsuit.  Perhaps that doc will drift off into Oxycontin® la-la land with the usual grace and lack of fanfare, or perhaps that doc will begin stewing about the injustice done to him.  Perhaps that doc will realize that he is effectively no longer constrained by the law.  If he decides to massacre the lying patient, the grandstanding Doctor B, the gullible judge and jury members, and the ringleading shyster, he would die of his illness before he ever went to trial.  So what's to stop him?

If you think this will never happen, you're wrong.  We live in an increasingly violent world.  We've seen fired postal workers "go postal."  We've seen boozing factory workers slaughter the foreman who canned them, and knock off a few co-workers for good measure.  We've seen high school kids, who feel picked on, turn their school into a bloodbath.  So will some doctor, facing death and hence with nothing to lose, try to right a wrong in this manner?  Yup, sooner or later, it will happen.  Probably later, given the yellow-bellied constitution of most docs.  (A related posting in my other ER site: Another Frivolous Lawsuit Attempt) From what I've gleaned watching Dateline and similar television shows, lawyers are, perhaps not surprisingly, more likely than docs to take the law in their own hands and kill whomever they please.  A few days ago, I saw a broadcast that told how an attorney near my old stamping grounds shot his wife through the head so he'd be free to continue his affair with an attractive judge, who, conveniently, presided over many of his trials.  Maybe I will call it collusion, after all.  Most judges and attorneys are too smart to get caught, so many such entanglements go unnoticed.

I think most judges are honest men and women who truly value justice.  However, I think their lack of familiarity with the intricacies of medicine makes them too apt to buy into the specious claims made by personal injury attorneys.  To compound this problem, most malpractice cases are decided by juries, not judges, because personal injury attorneys often demand a jury trial.  Why?  Because they know that jury members are likely to be even less medically sophisticated, and hence even more gullible, than a judge.  Juries are more inclined to decide on the basis of emotion, not facts, so the plaintiff's attorney will do his best to stir up those emotions and evoke a sympathetic verdict and a huge award.  In fairness to juries, they don't have it easy.  They must listen to expert witnesses with conflicting opinions.  How can they, as non-scientists, fairly hash it out?  Frankly, it's just a crapshoot.  That isn't just my opinion, that is easy to prove.  Simultaneously try a case in front of two juries, sequestered on opposite sides of a courtroom.  Do this 100 times, and see how often their verdicts agree.  The verdicts of The Jury from the Western Side of the Room will often not coincide with the verdicts of The Jury from the Eastern Side of the Room.  Hence, justice is just a crapshoot, and a doctor's entire life may hinge on who is selected for jury duty.  The best the doc can hope for is that his jury will be filled with smart, realistic, principled people who know that every time something bad happens, it isn't the fault of a doctor, and it isn't a reason to demonstrate sympathy by awarding an excessive amount of money.  Many attorneys think the bidding should start at a million dollars, and too many juries agree.  If I ever sit on a jury for a malpractice trial (fat chance of that, given that the plaintiff's attorney would use his peremptory challenge and boot me), I would do my best, if I thought the doc caused an injury, to assess the true compensatory value of that injury, not some reflexive, emotional impulse to make someone an instant millionaire.  So, if I ever did sit on such a jury, I wouldn't loose any sleep worrying if the doc on trial would some day put me in his crosshairs.

For all the lip service they give to bemoaning violence, the network news executives and anchors will be thrilled when Doctor A goes on a rampage.  It'll increase their ratings, so they will harp on and on about this.  Just like what happened in the school shootings, the publicity will plant this idea into the minds of other doctors.  99.999999% of them won't imitate the violence, but a few will.

Our justice system has hung innocent men, ruined their reputations, or just unfairly robbed them.  In theory, we bend over backwards in criminal trials to avoid the tragedy of an unjustified guilty verdict by demanding proof beyond a reasonable doubt.  In spite of this, human fallibility results in a distressing number of innocent people being punished.  In civil trials, the situation is even worse.  There, guilt is decided on the preponderance of the evidence or, more accurately, the preponderance of the hot air, sympathy, and the hand of fate that influences jury selection.  Sometimes flipping a coin would be more equitable.

If a jury proposes to ruin a man's life by depriving him of his liberty or just his bank account, why should the standard of proof be so radically different?  Sometimes there is a smoking gun that allows the jury to easily assess the truth, but in many cases, a verdict is just a stab in the dark.  Acting on instructions from the judge, they must find the defendant guilty if they think 51% of the evidence suggests that he is, but not guilty if 51% suggests innocence.  It sounds rational, but that 51% assessment is just a guess.  A crapshoot.  How can 12 people who did not witness something listen to expert witnesses who did not witness something (and are paid to favor whomever signs their paycheck), and then make a quantal pronouncement about something they've never done or likely even witnessed before and may have a tenuous grasp of?

Is there a better alternative?  In the case of alleged medical malpractice, there is.  Videotape every patient encounter.  If a patient alleges malpractice, the videotape of the encounter in which the alleged mistake occurred would be shown to a panel of doctors (of the same specialty as the accused doctor) along with a number of other videotapes of the same clinical scenario from patients who had no malpractice claim.  Then ask the physician panel to identify the error.  This is equivalent to the lineup shown to witnesses and victims of crime.  If a victim or witness cannot differentiate the perpetrator from the others, there is reason to question his identification of that person.  Similarly, if the physician panel cannot point to a specific error made by the doctor, it can be fairly concluded that the actions of this doctor did not meet the standard of malpractice.

This videotaping would make many doctors nervous, because if they botched something, it'd be impossible to deny.  However, such videotaping would be a nightmare for patients and attorneys hoping to profit from some bad outcome if the bad outcome was due to something other than a physician mistake.  Perhaps the patient did not follow directions, or perhaps he got an infection.  Even with perfect treatment, some wounds will become infected.  Blame God for putting bacteria in this world.  Or perhaps the patient smokes, drinks, has bad kidneys, is diabetic or elderly, or has some genetic susceptibility that makes him more likely to have medical problems.  Blame the doc?  Go ahead, but hope that he doesn't decide to settle the score when an impending death frees him from fear of the law.  It will happen, and when it does, I'll be there to say, "I told you so."  Not to gloat, but to use that as a platform for drawing attention to my idea of how to increase the fairness of malpractice cases.  I am not trying to shield doctors, mind you.  Had a physician panel saw my old doc prescribe a shoe lift for something that was obviously an ulcer (it was such a classic case that any medical student should have been able to not just diagnose it, but even localize it fairly well), they would have—when they stopped laughing about the shoe lift—awarded me some money.  Not a million dollars or some other ridiculous sum, but enough to compensate me for a few years of pain.  Perhaps $15,000, because my life wasn't a living hell.  I wasn't always in pain, and my life wasn't ruined.  My life went on.  Not perfect, but then it wouldn't have been perfect even without that quack's mistake.

If you're worried about the cost of the videotapes or DVD disks, don't be.  Their cost would be more than offset by the savings in insurance premiums (and Maalox®) that would accrue from an almost certain dismissal of baseless malpractice claims.  You make a mistake, you pay.  You don't make a mistake, and the patient has to make his million the old fashioned way.  That's justice, not a crapshoot.  However, it probably won't happen until a dozen doctors go berserk in their final days.  For all of the joy that our leaders derive from patting themselves on the back, most of them are just a bunch of bozos who aren't true leaders.  If they were half as smart as they think they are, they could prevent some problems before they occur.  Instead, they wait for something bad to happen, wail about it, and then make some half-hearted effort to forestall future tragedies.  Consider how Norman Mineta, President Bush's Secretary of Transportation, defends his cockamamie policy of nonselective screening.  Thus, airport screeners spend more time frisking old people in wheelchairs and breastfeeding mothers than they do checking out young Arabic men chanting passages from the Koran.  Until we see frail grandmothers commandeering aircraft and plowing them into national landmarks, it is absolute insanity to screen such people and let most Arabs pass with a wink and a nod just so Mineta can congratulate himself for being so politically correct.

To be successful, when the videotapes were scrutinized for possible error, we'd need to adopt realistic standards and not standards of perfection.  In theory, that is the way malpractice laws are already written.  In theory, a doctor is not held to a legal standard of perfection; he is held to a standard set by what an average practitioner of his specialty would do.  However, in practice, this is not true.  For example, an average doctor will frequently fail to diagnose patients who present with a pulmonary embolism (blood clot in the lung).  When I looked at the data on this a few years ago, I saw that doctors were just as likely to miss a pulmonary embolism (PE) as they were to diagnose one.  Many such diagnoses are only made during an autopsy.  Why?  Because diagnosing a PE can be difficult.  The symptoms and signs of a PE are very nonspecific, so it can masquerade as a number of other conditions.  In the ER, we could perform a test such as a pulmonary ventilation and perfusion scan, but the test results weren't clear-cut.  The radiologist does not tell the ER doc "this patient has a PE" or "this patient does not have a PE."  Instead, he'll phrase his guess (and that's just what it is) in gobbledygook that talks about "probabilities."  Sometimes a Ouija board would be just as helpful.  The ER doc is guessing that the patient may have a PE, and the radiologist makes a guess about probabilities, then the ER doc must guess if that guess is correct or not.  No room for error here, eh?  Yes, we have a "gold standard" test that is much more definitive, but it can't be done in some hospitals, and when it can, it's expensive, takes a lot more time, and it's risky.  Let's ignore the expense.  Time can't be ignored.  An ER doc does not have the luxury of testing every single patient with every single test to know with absolute certainty that every single diagnosis is correct.  If he did that, the ER would be so backed up that patients would be dying in the parking lot.  Risk cannot be ignored, either.  Some patients who have the "gold standard" test performed die from it, or experience other complications.  Hence, a doc can't be too trigger-happy about ordering that test, or any other test which carries a nontrivial risk.  So, a doc can make a guess, get a guess in return, guess about the accuracy of that guess, then guess whether or not it's a good idea to proceed with a confirmatory test.  Or a doc can just try to turn the radiologist's guess into a definite YES or NO, and act on that guess.  After all, the patient either has a PE or he does not.  He doesn't have some nebulous "probability."  It's there, or it isn't.  If the doc decides it's a PE, he can give heparin to thin the patient's blood.  That usually goes well, but an occasional patient is killed by it.  If the doc decides it's not a PE, the patient may die from it.  Or the patient may live in spite of the lack of treatment.  See what a quagmire this process is?  Unfortunately, there are many other conditions that are equally as muddy.  Such guessing and possible risks demonstrates how far we have to go in medicine.  People think we have such advanced technology.  Compared to what we had a century ago, it's miraculous.  But a century from now, doctors will look back on us and wonder how we got by with such Stone Age technology.  I don't need to wait a century; I'm wondering that very thing right now.  This uncertainty is risky for patients, a nightmare for doctors, and a gift from God for personal injury attorneys.  Those pillars of perfection don't need to wait a century to exercise their flawless 20/20 hindsight that makes those Monday-morning quarterbacks so smart.

Now you can understand why an average doctor misses so many PE's.  Theoretically, since an average doc is just as likely to miss a PE as he is to diagnose one (update:  the latest studies I read revealed that physicians fail to diagnose PE 70% of the time), how can a doc be sued for failing to diagnose a PE?  An average doctor is very likely to do the same thing!  Hence, if a doc is really no worse than an average doc, how is it legally justifiable to sue him?  If he is as good as the standard to which he is being compared, there is no malpractice, by definition.  However, that is just what happens.  It would make more sense to sue the scientists who haven't developed a better test, or to sue God for creating PE's and their diagnostic dilemmas, or to sue the know-it-all attorney because he failed to use his supreme intellect and infallibility in time to prevent the patient's death.

If we did not adopt realistic standards instead of standards of perfection, doctors would go on the warpath.  There is something that seems so intrusive about videotaping, especially when it's scrutinized with a microscope afterwards.  Stick a camera in someone's face and follow him around, and you're sure to uncover dirt.  Let's say a mother fails to thoroughly wash her hands before making some food that later induces illness in her teenage daughter.  The daughter is ticked because she missed the school prom, so she sues her mother.  Remember, the mother's mistake is captured in living color.  Did she make a mistake?  Yes.  Did the daughter suffer as a result?  Yes.  Does an average mother usually wash her hands well enough so that her family rarely becomes ill as a result?  Yes.  Mom, it's time to pay up.  In reality, I've seen parents make far more flagrant errors, such as carrying raw chicken on a platter to a grill, cooking it, then placing it back on the same platter without washing the platter!

Doctors should not be made to pay for every error they make until the same standard of perfection is demanded from everyone else in society.  People usually attempt to excuse their errors by uttering a perfunctory "sorry," but that does nothing to compensate the person who was victimized by the error.  In shopping at Home Depot, I've caught them charging me for two or three items when I purchase only one.  This happens so often that I now wonder if those duplicate charges are intentional or just a mistake.  Even if it's just a mistake, why should the cashier get off scot-free?  Don't docs pay for their mistakes?  Every time I catch such an overcharge, I'm told the same thing.  "Sorry, I can't refund the money to you.  You'll have to go down to Customer Service and request a refund."  That means standing in line, waiting for the clerk to process the refund, then keeping that receipt out for a month or two so I can verify that my credit card was indeed credited the amount of the overcharge.  Did the cashier pay for her mistake?  No.  But I did.  I've lost hours taking care of such problems at Home Depot.  Think they'd offer to compensate me for my lost time?  Ha!

Whether it is auto mechanics who don't fix your car the first time, service personnel who don't show up at your home on the appointed day that you stayed home to meet them, cashiers who pad your bill, or judges who release dangerous criminals back into society, it is clear that mistakes are not a rare event.  Some of us have comparatively trivial jobs, and the mistakes therein created are nothing more than an inconvenience.  Others have jobs with more potential for screwing up people's lives if an error is made, but some of these people—such as judges—are legally immune to the consequences of their mistakes.  Why should a judge face no personal risk, while doctors risk everything they have every time they step in to see a patient?

Except for doctors and business owners, most other people can make mistakes—even heinous ones—and never need to worry if they'll be sued.  I'm going to give a prize to the first person who can explain to me why this is justifiable.  Consider auto workers, for example.  They are well-paid, and receive great benefits.  I used to be an ER doc in Flint, Michigan, one of the big General Motors manufacturing cities, so I am well acquainted with the fact that many auto workers are stoned on drugs or booze while they are at work.  That's one reason why I refuse to buy a GM vehicle; perhaps the other US manufacturers have just as many zombies working on their lines, but I doubt that any corporation could have a worse problem in this regard.  Coincidentally, I am now reading a book called Rivethead, written by Ben Hamper, a former Flint GM "shoprat" (as he calls himself).  Hamper describes brazen drug and alcohol use, and even on-site booze sales.  Imagine the public uproar if I sold bottles of Jack Daniels in the ER so the nurses and I could get plastered and forget about all those miserable, whining patients.  Ya think the public would be pissed?  The State of Michigan would permanently revoke my license, and they would be entirely justified in doing this.  Any patient who was harmed or even wished he was would get a lawyer to sue me, and the jury would be so incensed they'd award punitive damages so high that suicide would be the only way to ever get out of debt.  Why am I, as a doctor, so liable for my actions?  Because what I do impacts the lives of other people.  Well, what others do can have a similar impact!  What if an auto worker doesn't properly tighten a bolt?  What if he doesn't weld something correctly?  What if he neglects to install some component?  Result?  The car might be a death trap.  An honest mistake is one thing, but when a man knowingly works in an intoxicated state, that's an egregious and wanton disregard for the safety of others.  So if someone is harmed as a result, why shouldn't that auto worker be sued for every penny he has?  I must sign my name and accept responsibility for everything I do; why shouldn't the same be true of others?  Not feasible?  Hogwash.  With today's technology, it'd be easy to identify who did what.

Hamper lambastes people who bitch about those stoned auto workers, implying that people who never set foot in an auto factory have no right to criticize on-the-job intoxication even if it results in crummy cars.  I've worked in factories . . . three of 'em, in fact.  My worst factory day was an absolute joyride compared to working in the ER.  The worst pressure I faced in the factory was when my foreman, a man I despised because he was cheating on his wife and a generally duplicitous bastard, would stare at me from a distance.  Did he want to fire me?  Screw me?  Or just intimidate me?  I never found out.  Hamper's factory must have been cushier than the ones I worked in, because he describes how workers would do their assigned job, and that of a co-worker, for an hour or two at a time so that person could read a book or do whatever he pleased . . . perhaps even trolling the factory and selling booze.  With this arrangement, at the end of a day, a man would have worked four hours, and had four hours off.  It may not have been heaven, but it certainly wasn't hell.  He said they could stretch their lunch breaks to an hour and twelve minutes.  Many of my lunch breaks lasted about five seconds, which was how long it took to slurp down a can of Ensure, often donated by a sympathetic nurse.  Some days I'd be too busy to spare even five seconds, so that can of Ensure was still rattling around in my pocket at the end of my shift.  Anyone who's never been a doc in a busy ER is probably wondering how anyone can be too busy to spare five seconds for lunch.  Trust me, it's true.  When you have a critical backlog of patients, a never-ending stream of ambulances depositing fresh carcasses every few minutes, and a dozen "I've been waiting too long" patients staring at me, it would have been professional suicide to touch my lips to a can of Ensure.  I can see the patient complaints now, "I'd been waiting for hours with my sick baby on the verge of death or permanent brain injury, and here's this doctor standing around drinkin' something!"  You think that's absurd?  You should see some of the truly groundless complaints leveled at me, such as when one mother complained that I didn't look at her enough . . . pardon me for obtaining the history from the patient, your 17-year-old daughter.  Sheesh!

Given that I worked in factories, and probably worse ones than Hamper, I think it's fair for me to compare what it's like to be an ER doc to being a shoprat, having been a shoprat myself.  I also think it's fair that I compare the medical profession to the teaching profession, since I've done that, too.  In a minute, I will describe how hellacious it can be in the ER.  Was teaching ever that bad?  Not even close.

Q:  (Considering the pros and cons of various alternative to medicine.)  Teaching, community service, fire/police, most scientific research:  pfft.  Lets just say the vast majority of time people who perform as vital a service to society as you do receive ¼ the pay and none of the status.  Some of them work as hard or harder.

A:  I agree that their contributions are equally vital.  It's like saying what is more important, food or water?  You need both to survive.  However, I disagree that some of them work as hard as I do.  I've taught before, and it was so much easier than being an ER doctor, there was no way to make a comparison.  Ten times easier and less stressful?  A hundred times?  Read the following excerpt from my book, and listen to what I have to say thereafter:

The popularity of the television show ER might give some idea of the responsibility shouldered by an ER physician, but I doubt that it can adequately convey the pressure an ER doctor faces while working in a busy emergency room. For example, it is not at all uncommon for several patients to arrive almost simultaneously in the ER, virtually on their deathbeds. Each of these people might require extensive interventions—like CPR, cardiac pacing, central venous line placement, and lumbar puncture—in addition to requiring intensive medical therapy. As the physician runs from patient to patient, he is often besieged by requests from nurses, ER assistants, residents, medical students, radiology technicians, patients, relatives of patients, paramedics, police officers, respiratory technicians, other physicians, hospital supervisors, and local TV stations and newspapers. Let’s step into the ER for a few minutes . . .

Nurse A shoves an EKG in my face, saying, "It's from the new guy they just brought in room 8; he's short of breath." The nurse scurries away, and I find that there is no chart for this patient. (Since that hospital had a policy against nurses taking verbal orders, it was incumbent upon me to assemble a chart so that I could begin writing orders on the patient. Great, I get to be a ward clerk, too.) Nurse B says, "The lady in room 12 is seizing, and we can't get an IV in her; the IV team tried, and they said that you'd have to do it." Nurse C demands, "When are we going to do the pelvic exam in room 10? The patient says she's tired of waiting." Nurse D informs me that the intoxicated, suicidal female patient in the Isolation Room walked out of the hospital three minutes ago. I requested the assistance of the hospital guard, and this insolent character had the temerity to refuse, saying, "Why don't you go get her?" Nurse E tells me that the family of the patient in room 7 is demanding to see me now. The clerk announces, "Dr. M. wants to speak with you on line 1, and Dr. V. is on line 3; he's mad because he's been on hold."

Another person announces on the PA system, "Dr. Pezzi to the radio room stat!" (to give orders on a critical patient coming in by ambulance). The respiratory technician tells me, "I couldn't draw his ABG (arterial blood gas). Do you want to try?" The radiology technician wants me to look at a cervical (neck) x-ray of a trauma patient who is clamoring to get out of his neck brace and off the backboard. The Internal Medicine resident approaches me, asking me to discharge a patient from the ER who was seen by the prior ER doctor and referred to the Internal Medicine service for admission. That's a tough position to be in, as the chart dictated by the first ER doctor will undoubtedly stress the need for the admission (to palliate the Utilization Review Committee). If I discharge the patient, and the patient has an adverse outcome, I am a sitting duck for a malpractice attorney.

An ER staff member tells me that I should go examine the police prisoner in room 2 so that the guy can be discharged back to the prison; the patient realizes that it is more pleasant to be in a hospital than in jail, so he decides that he's having chest pain and screams, "And I'll sue you if you don't admit me!" The patient in room 4 leers at me whenever I walk by, eventually yelling out, "Hey, Doc, I've been havin' this belly pain for three years. I want you to see me next!" The hospital public relations person is waiting to talk to me about three patients brought in with carbon monoxide poisoning; he tells me that Channel 12 wants to interview me "when I get a minute." A psychiatric patient follows me around like a little puppy, saying, "I'm depressed. I'm suicidal. Admit me." I discussed this with the on-call psychiatrist, and he refused to admit the patient. He declared, "That person is just a junkie!" The mother of the patient in room 6 screams at me, "My child is vomiting!!!"

Imagine 15 minutes of this, with ten hours to go until the shift is over. In reality, the scenario that I just depicted was even worse than how it was presented. For purposes of clarity, I relayed the dialogue from the first four nurses as if it occurred sequentially. Actually, those four nurses approached me at the same time and all four spoke simultaneously. After that, they darted away in unison, apparently complacent in their perfunctory discharge of their duty. I immediately implored, "Wait! I cannot understand what you’re saying when four people are speaking at the same time. You’ll have to repeat your messages one at a time."

Ever try to run three codes at once? I have, and you don't know what pressure is until you have. It's commonly accepted that a human cannot be in more than one place at a time, but ER physicians are expected to be immune to this limitation. If all patients who are being coded—and every other patient in the ER—are not treated as if they were the only person in the ER at that time, the doctor faces the very real possibility of a lawsuit. Realistically, ER physicians can be flooded with more patients at one time than they can optimally care for, but this fact is legally irrelevant, and cannot be used in their defense.

Imagine that you're a cashier in a supermarket, and a dozen customers with overflowing grocery carts come into your line, in addition to the ones who were already there. Imagine that you could be personally sued (losing your home, your car, money for your children's education and Christmas presents, and future wages) if you didn't check everyone out as fast and as flawlessly as you usually do. No, you can't simply make them stand in line and wait their turn. The analogy to ER is that some patients cannot wait; a patient who isn't breathing can't be scheduled for an appointment next Tuesday.

Imagine that one of the customers in your line, Mrs. Jones, has two carts full of groceries, a handful of coupons, and she must be checked out within the next four minutes—or else she can sue you, and she'll win. You'd love to accommodate her, but Mr. Smith and Mrs. Clinton are demanding the same thing, too. How would you feel if you were in this predicament? If you think it is so impossible that no one would ever be expected to deal with it, you're wrong. This is exactly the predicament which ER doctors find themselves enmeshed in every time the ER is swamped with critically ill patients—and that is not an uncommon event in an ER. If cashiers were subject to such potential liability, anyone who became a cashier would have rocks in her head. I feel the same about people who go into ER medicine.

To make matters worse, the efficiency of the ER is often impeded by a number of factors. Although I could fill a book with these snafus, I will mention only a few of them.

A couple of the hospitals at which I worked had trouble with their phone systems. Once, the phones were totally inoperable, but the hospital had a backup plan:  they allowed me to use the cellular phone in someone’s pickup truck in the parking lot. Consistent with Murphy’s Law, it was raining cats and dogs that night. Outgoing calls were a pain, but incoming calls were even worse since they’d often occur during the middle of a procedure. Another hospital spent one million dollars (hard to fathom, but it’s true) to upgrade their phone system, but the new system was a disaster. The volume of the handset was so low that I could barely discern what the caller was saying even when the ER was quiet—which it usually was not. I’d sometimes have to ask the caller to repeat himself so many times that it would have been comical had people’s lives not been at stake.

That latter hospital seemed to believe there was no task which could not be made more difficult by the implementation of ill-conceived technology. Rather than allowing us to read x-rays directly, they scanned them in the radiology department and we read them in the ER by viewing the x-rays on a monitor. Or, more precisely, we tried to read them. The problem arose because of inherent degradation in the resolution of the image imposed by limitations of the scanner and the monitor. As a consequence, subtle findings—which are often crucial—would be blurry. I could usually obtain the original x-rays, but that would require me to issue a request for them, then keep checking to see if they had arrived. On busy days, this was more than an annoyance, since anything which wasted my time limited the time I could devote to patients.

At another hospital, a couple of the consultants I’d often have to call at home were difficult to converse with, since one was invariably drunk and the other, from the background sounds, was evidently having sex with a 14-year-old girl. Must have been good stuff, because he’d ask me to "hold on for a minute" and then I’d hear them going at it. A minute or so later, he’d pick up the phone again, panting as the jailbait begged him, "Don’t stop now!" He would put his hand over the receiver of the phone, and I’d hear muffled voices and giggling. Then he’d pop back on the phone, "Sorry about that, Pezzi. Can you repeat the case again?"

I agree that some teachers work hard and bend over backwards to help their students, but show me a teacher, or a cop, or a fireman, or a scientific researcher, who faces such routine, intense situations.  While working in one intense ER, I bet I pumped out more adrenaline in one year than the entire police force in some counties.  I worked under incredible time pressure, taking care of too many patients with too many problems, all the while knowing that if I slipped up, someone could die, or sue me for every penny I had and might make in the future.  That's pressure.  Not handing out speeding tickets to people whose hands are shaking.  Not giving the same lecture to your students as you did the past seven years, and grading their papers as you listen to music.

And where do you get the idea that teachers make only a quarter what doctors make?  A few years ago, I read that the teachers in the area where I grew up made $60,000 per year working 180 days per year, and six hours per day.  Yes, I know it takes time to prepare lessons, but once that is done, it's done.  Say you're a history teacher.  Is there a need to revise history from year to year?  Or if you teach trigonometry?  Isn't that the same as when I took it, literally back in the last century?  Or English?  Isn't a noun still the same?  Don't we still abide by the same rules of punctuation?  My point is this:  once a lesson plan is created, with rare exceptions, it's done.  It might need a bit of polishing here and there, but most subjects taught to students are not radically revised from year to year.  Hence, this makes the teacher's job easier, and reduces their out-of-class workload.  Many teachers I knew eliminated the need for them to grade papers by giving multiple choice exams, and having students swap papers and grade them that way.  So, when the last bell of the school day rang, those teachers could head for home.  Do all teachers do that?  Of course not.  My Mom used to live across the street from a school, and I noticed one teacher who practically lived there.  Nevertheless, some of his colleagues made $60,000 for 180 6-hour days.  That's about $55 per hour.  At my peak, I made about $110 per hour, but when I moved to another area, I made $70 per hour for working the night shift and fucking up my sleep patterns so much that I still can't sleep for eight hours in a row.  $110 per hour may seem like a lot, but on December 2, 2002, the CBS Evening News reported that some personal trainers make over $100 an hour, and there are plenty of others who make as much or more.  I recently called to find a furnace repairman.  The first one I contacted charged $110 per hour for labor only (no parts); the cheapest one charged $45 per hour in addition to $45 for driving to my home (and he lives about 10 minutes away).  Or how about airline pilots?  Does anyone believe that flying an airplane is more difficult than being an ER doctor?  We don't have autopilots, but they do.  Even with their autopilots switched off, they can gaze at the beautiful horizon and have enjoyable discussions with the co-pilot.  They work far fewer hours, have less work-related obligations in their off hours, are never personally sued, and don't face massive fines from the government for omitting some paperwork that benefits only bureaucrats, not patients.  At the time I applied to medical school, I read that the average pilot IQ is 120 — definitely bright, but not as high as the average medical student IQ at that time (130).  Some people might think that being a pilot is, with a few exceptions, boring and routine, but others might opine that they work in a pleasant and glamorous milieu that gives them the opportunity to travel.  According to a friend who works for a major airline, pilots can tag along for free on flights when they're not working.  Thus, free airfare is yet another benefit they receive.  The February 17, 2003 issue of Forbes magazine reported that a 12-year pilot flying an Airbus A330 made $336,000 before wage concessions necessitated by the economic downturn and $193,000 at the current time.  First officer pay fell from $229,000 to $143,000.  I'm sure there are stresses associated with their jobs, such as the once in a blue moon cockpit excursion by a terrorist, but I can't believe that their average stress level is even a quarter of what ER doctors face.  By the way, Forbes also reported that retired pilots expect 50% of their annual pay, or up to $70,000.  Guess what my annual ER retirement pay will be?  Zero.  Hence, I reiterate my argument that ER doctors are not just underpaid, they are grossly underpaid.

UPDATE: I posted a related discussion on my other ER site: A Novel Look at Physician Income

I had far more education and training than a personal trainer, teacher, furnace repairman, or pilot.  Compared to my internship, working 115 hours per week and going for stretches of 36 or more hours of nonstop patient care, the internship of teachers is a dang vacation.

Let me broach yet another politically incorrect topic, and mention aptitude.  People who go into medicine are some of the smartest people around.  Are there smart teachers?  Of course, some are geniuses.  However, to make a valid statistical comparison, it's important to compare averages, not exceptions.  Every study I've read on this matter showed that education majors were near the bottom of the intellectual heap.  So, take people with less average aptitude, who take easier courses with less competitive classmates, and do that for fewer years than docs, then do a much easier internship, then work a job during the DAY (and not on weekends or holidays), and don't need to worry if they will be sued for ten million dollars as docs do if they deliver a premature baby from some gorked-out crack addict and the kid doesn't have all his marbles intact . . . so how on Earth can you even compare the intensity, the stress, the demands, the requirements, and the risks of being an ER doctor to that of a school teacher?  The school teachers in my Mom's district made about 80% of what I made at the end of my ER career.  To be generous to teachers, I considered their hours spent preparing lessons and grading papers.  If I also included the zillion and one hours I spent in continuing education, doing paperwork, attending meetings, and working hours of unpaid overtime per day, teachers made more per hour than I did.  And that's after I busted my butt for many years in one of the most rigorous educational programs ever conceived.  Here's my opinion about this matter:  the fact that a teacher's salary is anywhere near what an ER doctor makes is a testament to the fact that ER docs are not adequately compensated.  Sorry, I don't deserve just 20% more (if you ignore my unpaid hours), or about 20% less (if you consider all those mandatory unpaid hours).  Additionally, teachers receive benefits in addition to their salary:  health insurance, dental insurance, optical insurance, sick pay, personal days, retirement, unemployment insurance, life insurance, and who knows what else.  Most ER docs are "independent contractors" (as I was for most of my career).  That's a euphemism for saying "we ain't payin' for your health insurance, dental insurance, optical insurance, sick pay, personal days, retirement, or life insurance . . . if you want it, you can buy it yourself."  And unemployment insurance?  Forget about it.  Furthermore, as an independent contractor, I didn't just pay the Social Security contribution that everyone else pays; I paid the portion normally contributed by the employer.  My "sick pay" was nonexistent; if I didn't work, I wasn't paid.  Furthermore, it was incumbent on me to find a replacement.  If I couldn't, I had to show up.  This led to me working one night when I'd been vomiting for hours.  When I walked in the door, a nurse said I looked "green," so she started an IV on me, which I carried around on a pole during my shift.  Curiously, no patient commented on this.  Another night, I had such a bad cough that I could barely converse with the patients.  In desperation, I drank an entire bottle of dextromethorphan cough syrup.  Then I really got sick.  My boss, normally a bright and understanding man, later accused me of faking it just so I could call the next doc in two hours early.  Had he seen me that night, coughing when I wasn't puking, he wouldn't have said that.  I was peeved that I — someone who'd miss about one day every year or two — would be accused of malingering.  I wasn't one of the shoprats Hamper describes who think Monday and Friday are optional work days.  I was so sick that night that I didn't leave when my replacement arrived because the nurse taking care of me didn't think I'd make it home safely.  I concurred, so I spent the next eight hours in the ER doctor's room, with the IV still dripping away.  In the entire history of the world, has there ever been one teacher forced to work tethered to an IV pole?

Dang, being a teacher is looking a whole lot better now!  And being a personal trainer, furnace repairman, or pilot seems downright appealing!

Q:  Certainly the career I had planned doesn't seem very enticing any more.  I really enjoy computers, and planned to be a programmer or perhaps do some research.  But unless I somehow develop artificial intelligence personally, I'll never receive the recognition, the pay, the A-list women, or even make any real difference to anyone.  I don't want to die a friendless geek who lives in a cubicle and in a basement watching recorded TV reruns and eating Pringles.

Game development sounded fun . . . but the job is the hardest computer programming there is, has a high burnout and low pay and recognition.  Imagine:  working HARDER than you do round the clock debugging a game.

A:  I've worked round the clock for more than 36 hours straight treating blue babies and old men gasping for breath, comatose teenagers doing their best to check out of life 60 years prematurely, and listening to women wail as I coded their middle-aged husbands with bad hearts.  So if you think that programming Pac Man is more difficult than what I do, you're entitled to your opinion.  Just don't expect me to concur.

Q:  How bad is the sleep deprivation, and is there any reasonable way to avoid it?

A:  How bad is it?  It's horrible.  Until you've done it, you have no conception of how noxious long-term sleep deprivation is.  Can it be avoided?  Sure, if you don't go into medicine.  If you pick one of the cushy specialties (e.g., Physical Medicine & Rehabilitation), your life will be much easier.  And you'll be better paid, to boot.  Or, why not be a teacher?  You're the one who said that what they do is "as vital a service to society" as what I do.

Q:  (regarding sleep deprivation) That's the one thing that I think would kill me if there is no way around it.

A:  Prepare to die.

Q:  I feel tense, irritable, and just plain weird if I don't get at least 7 hours of sleep per night (6 is borderline).

A:  Oh, the personal injury attorneys will love you!

So six hours of sleep is borderline?  Try zero hours a few days per week.  But look at the bright side:  on your rest days, you may only have to work 18 to 20 hours.  I did that both in medical school, and during residency.  It was tons of fun, trust me.

Q:  You mention sleep deprivation in med school:  is that really necessary?

A:  No.  Medical school is really a piece of cake.  All those rumors about hard work are just a subterfuge to impress our future patients.  In reality, we'd spend 15 minutes per day learning to pronounce multi-syllabic medical words, then we'd head for the golf course.  After a sumptuous dinner each night, courtesy of the pharmaceutical companies, we'd head back to our luxury condos with another gift from the drug companies:  beautiful drug reps.  After a wild night of sex, we'd return to the ol' med school the next morning for another round of higher education.

Q:  What about the residency sleep issue?  Is it even possible to find a hospital offering a residency that's reasonable about hours worked?

A:  Yes, I've heard that Walt Disney is going to build a hospital where patients don't get sick in the middle of the night, or at other times that might inconvenience the doctors.

Oh, you want me to be serious?  Sorry, but I've spent so much time answering your questions that I've lost sleep and am now practically punch-drunk.  The state of New York enacted legislation prohibiting residents from working more than 80 hours per week, or more than 24 in a row.  From what I know about postgraduate medical education, I knew that the legislators were living in fantasy land if they thought they could easily change the time-honored rite of passage of torturing interns and residents with sleep deprivation.

In conclusion, you made being an ER doc sound so appealing, with the A-list women and all, that I was almost ready to dash back in the trenches of ER just so I could live the good life once more.  However, I just talked myself out of it.  Thanks for the memories, though.

Review of
TRUE Emergency Room Stories
by Kevin Pezzi, M.D.

Book info  Ordering info

Now available as a free e-book download

What really goes on in emergency rooms?  If you're a fan of the television show ER, you might think that you know.  Not so, asserts Kevin Pezzi, M.D., an ER doctor and author of True Emergency Room Stories.  Pezzi says the show ER only scratches the surface; the truth is far more interesting — and bizarre.  So bizarre, in fact, that the cases could shock even an experienced ER physician.  "I'm now a firm believer in the saying that truth is stranger than fiction," he says.  "I don't think that anyone could dream up such unusual stories."

Pezzi's book is packed with nothing but unusual stories.  There are no "the patient's in v-tach, shock 'em with 200 J and give 'em 100 mg of lidocaine, stat" type of cases.  While such cases are a mainstay of the show ER, Dr. Pezzi believes that they quickly become repetitious.  Instead, he presents an amazing collection of true stories.  The book begins with a story of how he may have saved Michael Jackson's life by averting an assassination attempt by a person who claimed to be a Cosmopolitan cover model, and ends with an interesting tale of how he was propositioned on a beach by a relative of a recent ER patient.  In between, he recounts stories of unusual murders and other crimes, truly odd reasons for dialing 911, unfathomable reasons for visiting the ER, and people with an extraordinary affinity for their pets.  Then there's a shocking end to a pregnancy, a twisted tale of revenge that would be a spellbinding plot for a movie, and the story of a man who attempted to remove his liver at home.

In this book, you'll accompany Dr. Pezzi as he meets the world's unluckiest man and woman, deals with people who have strange requests, and attends to a bride whose genetic disorder wasn't discovered until her wedding night.  There is also the story of the man who didn't know that he had been shot in the head, and the case of the pit bull who picked on the wrong person.

True Emergency Room Stories has something for everyone.  Besides the strange cases, readers will be captivated by dozens of incredible, tragic, humorous, steamy, heartwarming, thought-provoking, and poignant tales.

Still more ER questions Part 1

Still more ER questions Part 3

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

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