Why Practicing Medicine is so Hard in Today's Society

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Welcome back to More Than Medicine!

I hope everyone is enjoying the warmer weather, Spring is here!

This week, I wanted to share my own personal opinion on why practicing medicine in today's society is so dang hard. Of course, these opinions are simply my own and not a reflection of my employer or any other organization.

I want to start out by saying that I love my job and I love working as a PA. I know what I do is a privledge and I promise I try my best everyday not to take that for granted. However, like I am sure we all do, no matter how much you may love something, there are still frustrations. I've been a practicing PA for 2 years, but have 7+ years of experience working in medicine altogether (not including the shadowing experience I started accumulating in high school).

So you can say I've "been around the block" a time or two, (at the least). I will say that since I do work in the Emergency Department, that these frustrations are centered around the frustrations I feel in this specialty of medicine. I have no doubt that these frustrations will overlap with some from other specialities, but wanted to clarify the environment we are talking about.

Lastly, by all means not every single thing I am going to mention in this post will pertain to every patient. There are many patients that this list does not even come close to captivating their mannerisms, behaviors or expectations. BUT, I will say that there is definitely enough volume of patients that do that caused the idea to even come into my head in the first place.

Without further ado...

REASONS WHY PRACTICING MEDICINE IN TODAY'S SOCIETY IS SO HARD

UNREALISTIC EXPECTATIONS...

... With the hospital

I want to be very clear here when I say whenever you come to the Emergency Department, we do everything in our power to help you in every aspect that we can. However, we come with limited beds, and limited resources. Something I did not know until I was a PA-S and PA-C is that not all hospitals are created equally. This means, some hospitals will have more specialists, beds, an resources than others. A tertiary, research and academic hospital likely is a level 1 trauma center with academia, residents, and numerous specialists on call (such as ophthalmology, pediatric specialties, plastic surgery, ENT and orthopedic specialties broken down by category, such as hand, spine, etc.). A larger hospital may have 500+ beds to care for patients. In contrast, a community hospital may have 100-300 beds, and has basic specialties such as hospitalists, oncologists, orthopedics, cardiology, general surgery (to name a few). The specialists are not " in house" unless it is normal OR times or business hours. Every hospital will have different specialties available to them. For example, the community hospital I work at does not have hand surgery, ENT, ophthalmology, or pediatrics. If a patient needs to see one of these specialists emergently or urgently, I call to a hospital that does have the speciality, speak with the doctor on call, and THEY determine if patient needs transferred or can be discharged for close follow up outpatient. Believe it or not, some issues requiring these services may not need to be urgently seen in their office outpatient, either. So we can send a referral, but we cannot guarantee that you will see them the next day, or possibly, even the next week.

People often come to the ED thinking they will come in, see the ED provider, but also see the specialist. Unless your issue is unsafe to you or an organ/system to your body, you will not be seeing the specialist in the ED. Specialists see patients in the ED on an EMERGENT basis only. This does not mean that you're not important and it does not mean that we don't care what you are experiencing. I promise you, we do. BUT I will say that if the specialist saw every patient in the ED for every issue that was related to their specialty, well.. they would never go home.

... For chronic issues

The emergency department is for seeing patients with chronic issues that are acutely worsening that could possibly put your life, body organ, or body system at jeopardy for death or permanent irreversible damage. Examples of this are acute asthma exacerbations, CHF exacerbations, or COPD not improving with at home treatments. If these chronic issues are now worse and you cannot breathe, YES COME TO THE ED!! However, if you are coming to the ED for chronic back pain for 20 years, or chronic abdominal pain x10 years, and you've seen every specialty under the sun, follow with pain management, had multiple tests/work-ups and have routine follow ups with your specialist in addition to PCP, coming to the ED for a "second opinion" is not an emergency. We will happily still see you, however, you will unhappily be no closer to what is going on with you. We have X-RAYS and CT in the ED, along with basic labwork. We cannot do specialized testing or specialized labs. These need to be ordered by THE SPECIALIST. If you have the same pain for many years and there is no acute worsening, but today is the day you want to know what is going on, you will be disappointed when we likely cannot give you that answer. You need to see your specialist and your family doctor. The emergency department is for emergencies. I know we are fast and convenient care, however, as previously discussed we are limited on resources and can only do so much.

... For always finding an answer

One of the most common complaints in the ED is abdominal pain. A CT scan is a very helpful test. With it, I am able to look for life threatening conditions (AAA, aortic dissection, PE, perforated viscus) in addition to surgical emergencies (perforated bowel, high-grade organ lacerations, appendicitis). However, CT is not the most sensitive or specific test for everything. Neither is X-RAY or ultrasound. Some common things that can cause abdominal pain and NOT show up on ANY ED imaging are: irritable bowel syndrome, adhesions (scar tissue), peptic ulcer disease, and endometriosis. If I do a full abdominal pain work up on you with labs and imaging, and it is all negative (aka normal), I have successfully ruled out cause of emergent (surgical or non surgical) or immently life-threatening pathology causing your symptoms. If you are tolerating PO, and tolerating your pain, yes I am going to send you home. Does this mean that I do not believe you are having actual pain? No, it doesn't. I believe you. Does this mean I am saying NOTHING is wrong with you? No, I am not. Maybe you have a peptic ulcer, or if you're a female, endometriosis. However, if your imaging and labs are normal, you will need to follow up with your family doctor and referred specialist for additional testing. PUD is diagnosed on endoscopy, which is not done in the ED unless your PUD is hemorrhaging and causing unstable blood levels. I will start you on treatment if this is what I suspect is going on, and will send referral for GI. If your pain is due to endometriosis, this MUST be diagnosed by the specialist (OBGYN) and the only way to 100% diagnose it is with laparoscopic surgery. A statement I hear often is "well aren't you concerned that you can't find out what is wrong with me?" And that answer is no, I'm not. From the ED I have the tools to rule out life-threatening causes of abdominal pain in addition to causes needing emergent/urgent attention. I cannot simply find everything. Again, I do care about your pain, and will tell you how to manage your pain/symptoms at home, and will even prescribe medications if that's what's needed, but I cannot always find an answer.

I can also assure you that no ED provider would send you home if they thought something bad was going to happen to you or if we thought your life could be at risk.

IMPATIENCE...

Now more than ever, especially with so much information essentially instantaneously at our fingertips, our ability to wait for information, services or answers is nonexistent. Don't get me wrong, I also become impatient at times. A big example is when I am doing something that requires technology and it is lagging or not working properly. I just expect it to work at 100% efficiency 100% of the time, which is unrealistic. It's a natural thing to do. We are so used to clicking a link, doing a Google search, or watching a TikTok it find the answers we are looking for.

These expectations translate over into healthcare. For many reasons that I will not go into here, our healthcare system is flawed. As mentioned previously, our healthcare system also has limited resources. We have limited space and staff. We can only fit one person in the CT scanner at a time. Our phlebotomist can only tend to one patient at a time. This list goes on and on. With that being said, the Emergency Department is for delivering quick, life stabilizing care. There is never just one patient at a time. Because of this, we must prioritize our sickest patients first, such as the patients who will die if we do not imminently care for them. We have come up with a triaging process that allows us to care for the sickest people first. If you are coming in with a heart attack, you will not wait and will be seen first. You deserve to have the priority over someone coming in with a rash or a sprained ankle, no matter how long the other complaints have been waiting for. The thing about the ED is that people never stop coming in. We are open 24/7/365. If you are in the waiting room and don't see people coming in through the front door, I can guarantee you, people are still coming through the ambulance entrance in the back. Believe it or not, we thrive on trying to be as efficient as possible, and as ED staff we LOVE clearing the waiting room so no one is waiting. It's a nice feeling to have every patient in the department seen, and to feel like you're finally caught up. My point here is, we want you to be seen, too.

Often, people expect to walk into the ED and to be out within "a couple of hours". I can guarantee you, if you come to the ED for a low acuity complaint (rash, sunburn, bug bite, ankle sprain), you will not be out in 2 hours and you will wait. If you come in to the ED and are taken back right away, there is a good chance you are sick enough that you will be admitted and will likely not go home.

People expect answers once the X-RAY is done, medications as soon as the provider steps into the room, and the nurse as soon as the call bell is rang. You are important to us, and we care about your needs, however, you are not the only patient we are taking care of in the department. Nurses have multiple patients they are tending for. Providers with a long list of patients. Our ratios are NOT 1:1, and they never will be. On top of this, there are many moving components to the ED. Many smaller departments of services doing their part. Just to break it down for those who are unfamiliar:

When you come to the ED, you check in. Shortly after check in, you are triaged. This is where we determine how soon you need to be seen. If it is determend you are sick or unstable, you will be brought to a room. If you are determined stable, you will wait and likely go back out to the waiting room. Of course, your wait in the waiting room will vary based on your assigned acuity and the volume of the department. Once moved into a room, you will wait to see a provider, who is likely managing the care of 8-12 other patients at the same time. Once you are seen by the provider, we will do a history, perform a physical, make a differential, and decide what tests to order. From there, we will walk out of the room, back to our computer and place orders. Once we place labs, nursing staff or phlebotomy must collect supplies to go to your room and straight stick for labs vs. put in IV line. Once the labs a drawn, they are sent to the lab where it takes a couple hours for them to process the specimens. They are responsible for all lab specimens in the hospital, not just the ED. If imaging is ordered, your name is added to a list of other patients who need imaging done as well. Some modalities of imaging, such as US, are shared between ED and inpatient floors. The reason you are not getting your X-RAY, US or CT as soon as the provider steps out of the room is because they are currently with another patient, one who is either sicker than you, or, has been waiting longer than you. After your imaging is done, the study gets put on ANOTHER list waiting for the diagnostic radiologist to read the report. If we order you medication, know not all medication is kept in the department. Some medication needs to be made by pharmacy and sent up to the ED. This, of course, takes time too. This of course, does not include time it takes for reassessments and to consult specialists if needed. It is easy to see how it can and likely will take hours, for a standard ED visit. All because you are waiting, does not mean things aren't being done behind the scenes.

In a society where no one wants to wait anymore, please know, that waiting in the ED is a blessing, because that means you are not actively dying, and luckily, not the sickest patient in the department. You are lucky enough to likely be able to go home to your family, and spend another day with your loved ones.

THE INTERNET...

As I lightly touched on before, the internet allows us to have an infinite amount of information. Yes, I Google things too. Essentially every day of my life, multiple times. However, your Google search (likely of unrealiable sources) does not trump my medical degree. Healthcare personnel sacrifice years of their life pursuing this education and training. This does not mention the personal or financial sacrifices we have endured to be here, taking care of you. My point is, not only are we dedicated to your care, but we are qualified and trained to be here. If we do not order a test, it is because it is not clinically indicated. We have taken a history, and performed a physical, and determined it's not needed. This is our speciality. We are the experts in this field. Do you go to the mechanic and tell them how to fix your car based on a Google search? (Mindful that if they make a mistake to your car, it could potentially be life threatening...) My guess is no. When I seek services outside of the medical world that I am unknowledgeable in, I listen to their recommendations. No, this does not mean I follow blindly and don't ask questions. If there is something I don't understand, I ask about it. I encourage you to do the same with youre healthcare. If you are concerned or confused, ask your questions. However, if we practiced medicine based on your Google search, causing us to chase down proof you don't have an ailment that we already knew you definitely don't have based on your history, symptoms and exam, THAT would be practicing BAD medicine. Practicing that way will expose you to potential risks and harm. When we are treating you, we are considering the pros vs. cons of everything we do. I PROMISE we are giving you the best care we possibly can. In the ER, we are really good at having a wide, broad differential and using our clinical expertise with the help of diagnostic testing to rule out things dangerous to you. When we are creating a differential of potential diagnoses, I know we have numerous things that you've never even HEARD of before that we are considering. All because we don't list out every single little thing we are ruling out from the ED, does not mean we didn't consider it in the first place. If you are coming to the ED for our care, please allow us to do our jobs and care for you the best way we know how: practicing evidence based medicine.

LACK OF RESPECT...

This right here is definitely the HARDEST thing about working in healthcare. During COVID we were "heroes" and now most people treat us like the dirt on the bottom of their shoe. First of all, I don't care what you do for a living or what your social status is. Every human being deserves the decency of respect. We understand you are coming to us when you are sick, scared, and in pain. We are there to do everything in our power to help you. This DOES NOT give you the right to verbally harass, verbally threaten, or physically lay your hand on any healthcare provider. Aggressive behavior has no place in the healthcare system.

If you were to go to Starbucks and harass an employee, the cops would be called, you would be kicked out, possibly arrested, and you would likely never be allowed back at that location again. Although it seems as though that should be the standard everywhere, it isn't. Especially in the ED. We are expected to allow you to hit us, threaten us, and put ourselves in a dangerous situation because you want pain medication, are drunk, or simply just for the fact that you're seeking medical attention. Violence is never approrpiate. I know I can speak for my fellow colleagues and say that we did decide to work in the ED to help truly sick and vulnerable people. We want to do this, and we love doing this. However, we did not sign up to work in a hostile environment, where we are questioning our safety with every patient room we walk into. Instead of focusing on the medicine, we are also thinking about a safe hiding place if a patient were to attack us, wondering if security will come fast enough to save us, or scared that this patient will acually come to our house to "find us and kill us".

This should not be a reality. I am saddened to say it is. I don't have enough fingers/hands to count the number of violent encounters I have witnessed or that my colleagues have experienced since working as PA. The violence needs to stop and the police need to start charging and arresting people who act this way like they would if it were to happen to them, or if it were to occur LITERALLY anywhere else other than the ED.

Violence is NEVER the answer. Even if you're coming to the ED on your worst day, respect for others should still be the rule, not the exception.

In Summary...

I love working in healthcare. Working in healthcare is hard. Often, I think about other jobs I could have worked in, felt joy in, and would have been able to build a financially stable future with, too. I don't regret my decision to go into healthcare. It's actually the opposite. I am so grateful to be able to care for people and make a difference in the capacity that I do. Every job has its hardships, and I know that. I don't expect to change anything with this post, these frustrations will always be there, and that's okay (except for the violence, that is NEVER okay). If anything is to come out of this post, it is to raise awareness and shed a light for those who may not be aware. I hope it also raises awareness about the workplace violence we experience weekly in the ED, because truly, something MUST be done about this. This also serves as a gentle reminder that we are human, too, and just trying to do our best.

So next time you're seen in the ED, think back to this article and be kind. Be patient. Ask your questions. Be understanding. Have reasonable expectations. And know we care for you, we are here for you, we are advocating for you and we truly are doing the best we can with the staffing, resources, and space that we have.

XO,

Manny ❤️

P.S. do any of my fellow healthcare workers have a shared experience? Share in the comments!