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Speaking Your Mind

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All too often, good physicians lose their jobs because they won't spout the party line of their hospitals or groups. Sometimes, the truth hurts. Sometimes, policies are bad ideas. And sometimes, …

All too often, good physicians lose their jobs because they won't spout the party line of their hospitals or groups. Sometimes, the truth hurts. Sometimes, policies are bad ideas. And sometimes, even patients are wrong and customer satisfaction is a delusion. This presentation addresses the problem of muzzling good physicians. A danger to medicine across the board!

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  • 1. Breaking the Code of Silence: questioning authority and authorities Edwin Leap, MD, FACEP 24 May, 2007 Grand Rounds Department of Emergency Medicine West Virginia University Hospital
  • 2. Breaking the Code of Silence
    • Why should you care what I think?
    • I’m not an academic, not an administrator, not a researcher.
  • 3. Breaking the Code of Silence
    • You should care what I think because I care what you think.
    • And opinions matter, mine and yours.
    • Just ask a pollster; or a political candidate.
  • 4. Breaking the Code of Silence
    • But, you still may not; so grab a quick nap. There isn’t a quiz.
  • 5. Breaking the Code of Silence
    • I’m an emergency physician, which means:
    • Alcohologist, dispositionist, deceptionist, regulatologist, altercationist, paresthesiologist, analgesiologist, etc.
  • 6. Breaking the Code of Silence
    • My pedigree:
    • Marshall University, BS Zoology
    • WVU, MD
    • Methodist Hospital of Indiana, Residency
  • 7. Breaking the Code of Silence
    • Community Hospital Practice
    • 37,000 visits per year, nine partners, three PA’s.
    • One wife, four children.
    • Unknown number of dogs.
  • 8. Breaking the Code of Silence
    • I’m also a writer. Thanks in no small part to:
    • Mrs. McCarty’s English class, Barboursville High School, 1979-1982.
  • 9. Breaking the Code of Silence
    • But I didn’t write much until I was in practice, and my children were born.
  • 10. Breaking the Code of Silence
    • That is, until I began to really feel passionately about making the world better…for them.
  • 11. Breaking the Code of Silence
    • In 1997, I began writing for the Greenville News, Greenville, SC. ‘Chest Pain,’ was my first article.
    • I don’t write about cholesterol or foot fungus.
  • 12. Breaking the Code of Silence
    • I write about family, faith and medicine, and how old people can be so mean.
    • I write about fathers abandoning their wives and children, about mean drunks, the Confederate Flag, prescription drug abusers and lots of other things.
  • 13. Breaking the Code of Silence
    • In 2000, I began writing for Emergency Medicine News.
    • Monthly column, up to 2000 words.
    • Extreme editorial freedom. Very rare.
  • 14. Breaking the Code of Silence
    • What have I written about over the years?
    • What makes our job hard; what we endure at night; death; natural selection; abuse of our time; loss of our hope; loss of our passion; loss of our freedom; loving patients; disliking patients; loving doctors and medicine; disliking both.
  • 15. Breaking the Code of Silence
    • I’ve also written about: Pay for Performance; the LLSA; the pain scale; patient satisfaction scores; crazy people; sad people; violent people; drug abusing people; unprofessional doctors; home-schooling; parenting…
    • The list keeps growing.
  • 16. Breaking the Code of Silence
    • I may not be doing formal research, or cutting up rats to examine hepatic mitochondria.
    • But I’ve learned a lot about emergency medicine.
  • 17. Breaking the Code of Silence
    • People send me their stories and tell me their frustrations.
    • I get a look inside the lives of my colleagues, and inside the dynamics of our field.
  • 18. Breaking the Code of Silence
    • And to this day, I get notes that say:
    • ‘Thanks for saying that.’
  • 19. Breaking the Code of Silence
    • ‘You said what I was feeling, but didn’t know how to say.’
  • 20. Breaking the Code of Silence
    • ‘I’d say it, but I have no place to do so.’
  • 21. Breaking the Code of Silence
    • ‘I thought I was the only one…’
  • 22. Breaking the Code of Silence
    • I’m always touched by ‘I thought I was the only one.’
    • One of the most terrifying feelings is the sense of isolation.
    • If you feel or think something, chances are you aren’t alone.
  • 23. Breaking the Code of Silence
    • Even if what you feel or think is, well, odd.
  • 24. Breaking the Code of Silence
    • I occasionally get notes that say I’m:
    • Unprofessional, burnt-out, insensitive, unkind, judgmental, hyper-religious, environmentally uncaring, etc.
    • A writer who offends no one isn’t much of a writer.
  • 25. Breaking the Code of Silence
    • Just ask this guy: Salmon Rushdie, author of ‘The Satanic Verses.’
  • 26. Breaking the Code of Silence
    • I often receive letters through EMN that say:
    • ‘I like what you said! It was so true!’
    • ‘But please don’t print this letter.’
  • 27. Breaking the Code of Silence
    • Far worse, I get comments like these:
    • ‘I’d say what you did, but I’m afraid.’
    • ‘I’d love to say that, but I’ll get fired.’
  • 28. Breaking the Code of Silence
    • Let me repeat that:
    • ‘ I’ll get fired!’
  • 29. Breaking the Code of Silence
    • And this from prominent physicians!
  • 30. Breaking the Code of Silence
    • I chose to talk about questioning authority, in large and small ways, because many physicians are afraid to do just that.
  • 31. Breaking the Code of Silence
    • In America today, doctors fear firing, or censure, loss of tenure or loss of income, if they speak their minds.
    • I don’t mean speaking their minds like Imus.
    • Just the truth, as these doctors see it.
  • 32. Breaking the Code of Silence
    • See, crazy me, I always thought that these people…
  • 33. Breaking the Code of Silence
    • And this document…
  • 34. Breaking the Code of Silence
    • Meant to preserve the free speech of everyone.
    • Factory workers, housewives, politicians, children, immigrants and educators…
    • Even doctors.
  • 35. Breaking the Code of Silence
    • So, how did medicine get here?
    • We used to be independent thinkers.
    • We used to believe our opinions mattered.
  • 36. Breaking the Code of Silence
    • What did doctors do before they became so afraid to speak?
  • 37. Breaking the Code of Silence
    • Challenged superstition and tradition.
    • Dared to open the dead, and living, human body.
    • Believed that even the poor, powerless and diseased deserved help.
  • 38. Breaking the Code of Silence
    • Over thousands of years, they, we, learned to use science to stand against time honored (and often wrong) traditional treatments, based on observations and, initially, on opinions.
    • Research and education and health systems began with the good ideas of individuals.
  • 39. Breaking the Code of Silence
    • Have we now come full circle?
    • Does the weight of science or popular opinion crush individual objections, individual opinions?
  • 40. Breaking the Code of Silence
    • In other words, in an evidence based, double-blinded, placebo controlled world, does your opinion matter?
    • In a consumer driven, highly regulated profession, does your opinion matter?
    • Or is your opinion always to be subject to the power of everyone else’s?
  • 41. Breaking the Code of Silence
    • Is it possible that the opinion of one, or a few, can actually be correct, while the opinion of many others is wrong?
  • 42. Breaking the Code of Silence
    • Ever heard of eugenics?
    • Sounded like a good idea.
    • Supported by prominent people.
  • 43. Breaking the Code of Silence
    • Sir Francis Galton, cousin of Charles Darwin
    • Alexander Graham Bell
    • Winston Churchill
  • 44. Breaking the Code of Silence
    • Theodore Roosevelt
    • Margaret Sanger
    • The Rockefeller Foundation
    • The Carnegie Institute of Washington
  • 45. Breaking the Code of Silence
    • And this fellow:
  • 46. Breaking the Code of Silence
    • Who incorporated the theories of eugenics into his racial policies, in order to purify the world.
  • 47. Breaking the Code of Silence
    • Some US research funding was even involved in the early genocidal activities of Nazi Germany.
    • Smart people, big corporations, new ideas, must be good, right?
    • Wrong.
  • 48. Breaking the Code of Silence
    • Are all of us stupider than any one of us?
  • 49. Breaking the Code of Silence
    • Well, I’ll tell you right now:
    • Your opinion matters, even if it’s a minority.
    • This is very important to the future of medicine, and your fulfillment.
  • 50. Breaking the Code of Silence
    • Anecdote gets a bad rap, as if our own experiences are false, our own eyes blind, our own hands numb.
    • Only collective opinion and research seem to matter.
  • 51. Breaking the Code of Silence
    • Anecdote, your observations, matter. What you do and see, and how you perceive it matters.
    • Every patient you see, every experience you have, adds ‘data points’ to your brain.
    • Every political and social scenario that involves you teaches you.
  • 52. Breaking the Code of Silence
    • In fact, you must never underestimate the power of your own observations.
    • Every practice location has unique people, conditions, situations and pathologies.
    • Not every ivory-tower observation applies to your hospital, or your practice.
  • 53. Breaking the Code of Silence
    • Physicians have often been individualists, struggling against larger forces.
    • Let’s look at a very tiny sample of physicians who stood against authority.
  • 54. Breaking the Code of Silence
    • Galen, AD 129-200. Not allowed to dissect humans, so used animals to learn about anatomy. Also worked in a gladiator school. Did brain and eye surgery, as well as cataract surgery.
    • Talk about shooting from the hip!
    • Had very few double blinded studies to rely on.
  • 55. Breaking the Code of Silence
    • In 1797, Baron Dominique-Jean Larrey, Chief Physician for Napolean, developed first prehospital system for battlefield injuries.
    • He clearly saw that the men, and the army, deserved better.
  • 56. Breaking the Code of Silence
    • Dr. Elizabeth Garrett Anderson, LSA, MD,
    • 1836-1917.
    • Who was she?
  • 57. Breaking the Code of Silence
    • The 1 st woman to gain a medical qualification in Great Britain.
    • She was refused admission to many medical schools.
    • Eventually accepted, but for 19 years the only woman in the British Medical Association.
  • 58. Breaking the Code of Silence
    • We take this for granted. But apparently, the general feeling was that ovaries and breasts might get in the way of proper medical decision making.
    • How silly! Everyone knows that it’s actually make-up and jewelry that are the problem.
  • 59. Breaking the Code of Silence
    • Dr. Emily Barringer 1876-1961.
    • First woman to secure a surgical residency.
    • What was she thinking?
  • 60. Breaking the Code of Silence
    • What lecture would be complete without Sir William Osler?
  • 61. Breaking the Code of Silence
    • Contrary to popular opinion of the day, he moved medical training from the classroom to the (gasp!) bedside.
    • ‘If you listen carefully to the patient they will tell you the diagnosis.’
  • 62. Breaking the Code of Silence
    • Of course, he also invented the idea of the open-ended, difficult, ‘live in the hospital’ residency program.
    • We’ll forgive him for that…
    • It was worth some laughs.
  • 63. Breaking the Code of Silence
    • Christian Albert Theodor Billroth 1829-1894.
    • 1 st Esophagectomy, 1 st Laryngectomy.
    • 1 st Gastrectomy for gastric cancer ‘after many ill-fated attempts.’
  • 64. Breaking the Code of Silence
    • Nearly stoned to death in Vienna when 1 st Gastrectomy patient died after the procedure.
  • 65. Breaking the Code of Silence
    • Doing something new, something unheard of, often has a price.
    • Like firing, banishment, mistreatment or death.
  • 66. Breaking the Code of Silence
    • Ignaz Phillip Semmelweis, 1818-1865.
    • Believed that hand-washing would drastically reduce deaths in obstetric clinics.
    • Physicians felt it ‘took too much work.’
  • 67. Breaking the Code of Silence
    • Here’s a test question:
    • What is the ‘Semmelweis Reflex?’
  • 68. Breaking the Code of Silence
    • ‘ The dismissing or rejecting out of hand of any information, automatically, without thought, inspection or experimentation.’
    • (Or sometimes, these days, accepting information without adequate thought).
  • 69. Breaking the Code of Silence
    • Like this, for instance: ‘It can’t be appendicitis, the WBC is normal!’
    • Or this: ‘Don’t ever give narcotic pain medication to a patient with an acute abdomen.’ (Always let them suffer).
  • 70. Breaking the Code of Silence
    • Or this: ‘If you don’t give thrombolytics for stroke, you’re not doing the right thing! We’re a stroke center, for heaven’s sake!’
  • 71. Breaking the Code of Silence
    • After all, if senators and congressmen think a therapy is the right one, and if it’s on WebMD or Oprah, it has to be good!
  • 72. Breaking the Code of Silence
    • Fortunately, doctors do ask questions sometimes.
    • Like ‘Why can’t I give my patient morphine while you finish your office hours before surgery?’
    • Or, ‘Maybe we could give tPA for strokes, but not quite as often…’
  • 73. Breaking the Code of Silence
    • See, sometimes a person takes a chance and makes a revolution, against common practice or opinion.
    • Like the early heart surgeons.
  • 74. Breaking the Code of Silence
    • In 1966, a white paper by committees of the National Academy of Sciences, titled ‘Accidental Death and Disability,’
    • Found that 50% of all EMS in America was performed by 12,000 morticians.
    • It began with individuals saying ‘we can do better!’
  • 75. Breaking the Code of Silence
    • Physicians recognized the incredible need for professional EMS, and a new specialty.
    • Cincinnati General Hospital started the first residency in 1970.
    • It revolutionized emergency care!
  • 76. Breaking the Code of Silence
    • Here’s another, from my own world. Not as dramatic, but illustrative:
    • Pat Johannes, MD, FACEP.
    • Director of my group.
    • Looked at SC Blue Cross/Blue Shield reimbursement and said ‘we’ll pass, thanks.’
  • 77. Breaking the Code of Silence
    • Conventional wisdom? You can’t decline to accept BC/BS. They’re too big!
    • Not where we live! And soon, other groups followed suit.
    • Our reimbursement went up from BC/BS patients.
  • 78. Breaking the Code of Silence
    • We’re still waiting on the BC/BS Ninja’s to come to his house and garrote him.
  • 79. Breaking the Code of Silence
    • Other issues? Over-crowding. For years we were saying ‘hey, it’s crowded in the ER!’
    • For years, administrators said, ‘Yeah, deal with it! We have a hospital to run!’
    • ‘Keep the chaos in the ER.’
  • 80. Breaking the Code of Silence
    • We knew it was a problem.
    • Guess what? It is! And now, thanks to daring thinkers in our specialty, hospitals have to deal with the problem as a whole.
  • 81. Breaking the Code of Silence
    • Here’s the thing: you may not all be researchers, academics or administrators.
    • But you can be mavericks wherever you practice. You can change things for the better.
  • 82. Breaking the Code of Silence
    • But only if you’re both honest and courageous.
    • You could change the face of emergency medicine from wherever you find yourself.
  • 83. Breaking the Code of Silence
    • But you can’t simply conform.
  • 84. Breaking the Code of Silence
    • What other controversies has our specialty faced?
    • How about fair group practices?
    • Conventional wisdom says, ‘I own the contract, I get the money, you get the holidays!’
  • 85. Breaking the Code of Silence
    • The founders of AAEM led the charge, and today the landscape is different in emergency medicine.
    • Not perfect, but different.
    • Because someone was willing to challenge the status quo.
  • 86. Breaking the Code of Silence
    • It applies in large issues and small:
    • You must lavage all overdoses!
    • Then, you must give charcoal to all overdoses.
  • 87. Breaking the Code of Silence
    • Most of us who saw them realized something:
    • They fell asleep, we intubated them, they woke up angry, they signed out AMA.
    • No matter what we did!
  • 88. Breaking the Code of Silence
    • Now we know that it was a reasonable thing to do in most overdoses.
    • Protect their airway. And…
    • ‘Don’t just do something, stand there!’
  • 89. Breaking the Code of Silence
    • My point is simply that our opinion, gathered from experience, is vital.
    • Research fluctuates, research can be well done or poorly done, industry driven or not.
    • The Hawthorne Effect is a real concern.
  • 90. Breaking the Code of Silence
    • Rib belts good, rib belts bad, rib belts good…
    • Computers in medicine will reduce errors…or maybe increase them
  • 91. Breaking the Code of Silence
    • Privacy needs to be protected!
    • Passwords are a pain in the bottom.
    • Computerized records are great.
    • Computerized records may deteriorate.
  • 92. Breaking the Code of Silence
    • Black Box warning for Inapsine!
    • We have to stop using a dangerous drug!
    • Oh, heck, we’ll use it anyway because it is actually pretty safe.
  • 93. Breaking the Code of Silence
    • Soft cervical collars, rib belts, sterile suture technique, ATLS guidelines, ACLS guidelines.
    • The list goes on and on.
    • Research, critical to our work, is always changing.
  • 94. Breaking the Code of Silence
    • There are large and small issues we need to face courageously.
    • What about the ‘Customer Service’ mentality of modern medicine?
    • Is it the right thing, or the wrong thing?
  • 95. Breaking the Code of Silence
    • My contention is that if you don’t pay for a thing, you cease to be a customer.
    • ‘Customer’ has a different ethical and moral obligation from ‘patient’.
  • 96. Breaking the Code of Silence
    • Patient satisfaction surveys are also suspect.
    • But we do them anyway, and doctors are afraid of them, so do things they might not otherwise do.
    • Is this wise? Is this good medicine?
  • 97. Breaking the Code of Silence
    • Does it make us better doctors to offer free movie tickets to patients who wait too long?
  • 98. Breaking the Code of Silence
    • Some suggest that we have no waiting room.
    • Do we need a waiting room?
    • Are we bad doctors if someone has to wait two hours for a hangnail?
  • 99. Breaking the Code of Silence
    • The treatment of chronic pain and acute pain.
    • Does the pain scale supplant my years of experience?
    • Does JCAHO know how to treat the sick?
  • 100. Breaking the Code of Silence
    • Did the IOM report on error make us more careful?
    • Are we really killing all of those people, or were many of them already dying?
    • Maybe we are, but is it reasonable to ask?
  • 101. Breaking the Code of Silence
    • Not everyone thinks we should ask.
    • Many think we should simply apologize and make every effort to look better for our customers.
  • 102. Breaking the Code of Silence
    • In order to look better for the public, along came the LLSA/Concert Exam.
    • Rather than hire a PR firm to counter charges of our ‘incompetence’, we said, ‘Oh what can we do?’
  • 103. Breaking the Code of Silence
    • Believe it or not, I have it on good sources that there was contention between ACEP and ABEM about the LLSA idea.
    • Physicians in practice, who have to pay the fees, read the articles and take the tests, believe it won’t help them.
  • 104. Breaking the Code of Silence
    • Trust me when I say, people are still upset.
    • And so is ABEM. The ABEM president called me at home.
    • Yikes.
  • 105. Breaking the Code of Silence
    • What about the idea that you have to be in a teaching center to practice good medicine?
    • That you have to be on 12 committees, work with 2 EMS services, and teach medical students, in order to be a good doc?
  • 106. Breaking the Code of Silence
    • What about the fallacy that you can get filthy rich in Emergency Medicine?
    • What about the idea that maybe you could use your flexibility to know your spouse and children?
  • 107. Breaking the Code of Silence
    • Whether you are in a position of authority, or just work in a small hospital, don’t be afraid to question the status quo.
    • By your very education, your practice, your love of people, you have more knowledge than you can imagine.
  • 108. Breaking the Code of Silence
    • So never be afraid to speak, or ask, or dissent.
    • Do it with respect, and with honesty.
    • Do it without rage or profanity.
  • 109. Breaking the Code of Silence
    • And if you are in a position of authority, teaching, researching, managing, learn to listen to the ‘unimportant’ people.
    • They might have a really good idea.
  • 110. Breaking the Code of Silence
    • But whatever you do, honor your medical ancestors, and those who gave you free speech, and refuse to be silent when you see something, clinical or non-clinical, that needs to be questioned or changed.
  • 111. Breaking the Code of Silence
    • If you don’t, you dishonor the past and silence the future.
  • 112. Breaking the Code of Silence
    • Thanks for letting me visit.
    • It’s an honor to speak to old friends and new.
    • Visit my website sometime:
    • www.edwinleap.com.