Crash Cart: The Drop Out Club, palliative care, and a patient’s guide to the ER

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This week: Docs talk about leaving medicine; Does palliative care belong in the ER?; Patients knowing how to properly utilize ER services. Join in as our editors discuss the week’s headlines.

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The first rule of Drop Out Club is talk about doctor burnout with like-minded doctors

While one study found that over half of all US physicians are experiencing the symptoms: loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment, it’s been a verboten topic with colleagues. Online communities are providing comfort, counsel, and courage to physicians in need of it. Original Article by STAT News.

Nicholas Genes, MD, PhD: I’ve been a member of DOC for the better part of a decade. The New York Chapter meetings are pretty good – lots of opportunities to meet with employers, entrepreneurs and others looking for consultants or medical expertise. The job listings have always been a bit of a head-scratcher to me: it’s either entry-level analyst positions at major firms that can’t possibly pay as well as an MD, or leadership positions at pharma labs that probably could be more selective with recruiting. Still, there are 800,000 physicians in the US and DOC (which is free, and worldwide, and has lots of lurkers like me) has only has 37,000 members – suggesting 95% or more of this country’s doctors aren’t desperate to quit.

E. Paul DeKoning, MD, MS: I’m not sure which is worse, the fact that so many are struggling with the thought of quitting, or the stigma they [at least think]they face for considering it in the first place. Neither are good. Is it any wonder, then, that we find ourselves wondering why we see the effects of reaching the breaking point–suicide, substance abuse, relationship behaviors, etc. Kudos to those who aren’t afraid. Even more to those who step out in spite of their fear.

Jyoti Mahapatra, MD: I would bet my next day off that the number of physicians wanting to leave medicine is staggering compared to the number of the DOC’s actual members. Most are too afraid to say it out loud, and declare to the world that all those years of schooling have not brought the fulfillment we all hoped for. There would be too much shame and disappointment from friends and colleagues if a physician ‘gives up’ and leaves medicine. And then there is the crippling debt that many physicians liken to serving a lifetime sentence with no hope for early parole. I am curious how the DOC members are stratified by field of practice. I doubt a lucrative cosmetic dermatologist is looking for a desk job at Tricare. But there are plenty of EPs, PCPs, and intensivists dreaming of a healthier lifestyle for themselves and their families. Through closed social media groups I have witnessed an inspiring professional renaissance that EPs and other physicians have created. CMOs, medical missions, telemedicine, IC, insurance consulting, case reviews, administration, simply cutting back on shifts, FSED and serving rural sites would all technically fall under the category of ‘dropping out’, from the traditional 36 hour hospital work week in a busy ED. But these doctors have brought meaning back into their careers whether or not they include direct patient care. These may be stepping stones towards another career or a refreshing reprieve on the way back to the ED. Either way, we need to market ourselves so that fewer physicians feel trapped rather than blessed to practice medicine.

Jaime Hope, MD: This is more common than people think. Interestingly, sometimes it can be a case of thinking the grass is greener. Every job has its good and bad points. People go to cosmetic and concierge Medicine thinking it will remove administrative and insurance headaches but then feel frustrated with patient’s unrealistic expectations and other problems. And people are hoping for jobs that will pay doctor-level salaries (or more!) that are easy. The reality is more entry level like Nick said. There are some amazing opportunities out there but you have to work to get them and keep them. We need more robust resilience training, encouragement of seeking outside hobbies, acceptance of part time schedules, and support each other. We don’t want to chase all of the caring, ambitious physicians out of medicine!

Seth Trueger, MD, MPH: https://twitter.com/MDaware/status/777552671121272837

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A CDC study says 1 in 6 trips to the ER is made by an older patient, and another says half of elderly visit the ER in their last month of life

Of those, half die in the hospital, even though they’d prefer to die at home. While there are obstacles—the 149 emergency physicians have become certified in it since it emerged a decade ago leaves a national shortfall of as many as 18,000 palliative care doctors–many are seeing the potential benefits to palliative care in the ER. Original Article by NPR.

Nicholas Genes, MD, PhD: When I saw this headline, I had hoped they’d interviewed Corita Grudzen. I’m glad they did, and she even cited our work at Mount Sinai. Of course it would be great to have the palliative care discussion before an ED visit, or at some point during an inpatient stay – but we EPs should be accustomed, by now, to making do with failures in other parts of the healthcare system. We’ve run helpful articles in EPMonthly over the years on how to frame these difficult decisions and sensitive conversations in the ED – but with the silver tsunami upon us, the need is growing.

E. Paul DeKoning, MD, MS: I agree with Nick. The need will continue to increase as the aging population continues to come to the ED for care. I’ve been amazed at how often the treatment goals discussion takes less time than I would have thought. As people who thrive on solving problems, we need to be willing to not do something but rather just stand there. And perhaps just hold a hand.

Jyoti Mahapatra, MD: I have given a lot of thought to palliative care as my ‘Drop Out Club’ back up. Watching our aging population suffer intervention after intervention with no improvement in their quality of life is insufferable. I would gain so much more meaning from my career by helping someone spend their last months, weeks, or just days on their terms. And be the one to have the difficult conversations with family, the kinds of conversations EPs already excel at, especially when we have to ask the questions that bizarrely no PCP or oncologist has already brought up. I hope we will see increased utilization of palliative care resources rather than a mirror of the decrease in social work support in the ED.

Jaime Hope, MD: Like Jyoti, I have been giving this serious consideration. The death rate remains steady at one per person, Medicine hasn’t changed this fact. As an EM doc, I love helping people! Sometimes that involves medications and fun procedures, sometimes it simply involves caring for someone as a human. Having the honor of caring for a family member with pancreatic cancer, I have been reminded repeatedly about the importance of care AND caring. We need more of this in EM!

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As more hospitals close their ERs – 22 percent fewer than two decades ago – the average wait to be seen is 55 minutes, and complaints abound

Knowing how to properly utilize ER services can make for happier patients—and physicians. Original Article by The New York Times.

Nicholas Genes, MD, PhD: Good for Jane Brody and the NYTimes for tackling this important topic. It’s not exactly what I would have written, but close. I just wish more of our patients read the Times. Now that I think about it, I also wish more could “practice self-calming measures” or “keep a list of all medications and supplements” or have ready access to an “advocate or helpmate.”

E. Paul DeKoning, MD, MS: I feel like I need this in my waiting room. Along with a placard identifying that exits are here and here and that an emergency slide will deploy if necessary. Oh, and vomit bags.

Jyoti Mahapatra, MD: If there was a Pokémon Go game for the ED, no patient would ever ask us how much longer its gonna be or that all their medical history should be in your chart. Just sayin.

Jaime Hope, MD: Pokémon GO EM version is brilliant!  Or any game based way to educate people about what we do.  Hmmm…alternate career idea?

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