So many thoughts, so few columns remaining. I was lying quietly on the pre-op stretcher waiting to have my last cataract out last week when in walks the pre-op nurse, who we shall call Janet. “Dr. Henry,” she says quietly, “it’s been a long time.” “Is that really you?” I said, as she smiled and attended to the business of getting me ready. She and I had come to that hospital in 1970. I was a third year medical student and she a fresh-out-of-school RN. We have bumped into each other frequently over the past 46 years, always nostalgic, always with a smile.
“So, do you ever think back on our old times in the ER together?” I said. “All the time,” was the reply. “What do you remember most about those days, as compared to today?” I queried. “We were all very young, Greg.”
We were brash, cocksure, bright, arrogant and quick to defend our choice of liking the emergency room. Eclectic, wild and wooly would be the kindest way I can describe the ragtag army of emergency docs in those days. There was an immediacy, a need to create, a need to establish, a need to be accepted that has faded somewhat as the 215 residencies [then there were only five] have now come to dominate the scene. Our only bona fide was the love of what we did. We were “without portfolio or pedigree” but it didn’t matter. We were adventurers in a new land and we loved it. “You guys were something else,” she said, remembering. “And I still refuse to tell you what we called you behind your back.”
As she worked, the process was perfect. The people who greeted my wife and I that day were attentive in the extreme. As I stuck out my hand to get the IV, Janet used what must have been a 33-gauge needle to prep the skin with Lidocaine – absolutely no discomfort. A 21-gauge was inserted to carry the IV fluid and again not one moment’s pain. Both the nurse anesthetist and another old acquaintance stopped in; the anesthesiologist came in and finally my ophthalmologist, a friend for 25 years, came in to place his initials in indelible pen over the correct eye. That was it. In 25 minutes I was back in the room without a cataract. It could not have been sweeter. Thank God.
As I was about to say goodbye to Janet, I had just one more query for her: “Why did you leave the ER, if you loved it so much?” “Greg, I would have never lasted till ’69 in medicine if I had stayed in that psychic hellhole. And it wasn’t just the shifts or the patients that drove me out.” Now I knew I was onto a potential column topic, so I had to ask: “So, in a word, what was it?” Without hesitation, she looked at me and said: “Anger. Look around you here, everyone here in this outpatient surgery center is happy. The patients are nice and they want to be here and they want our help. The doctors scheduled this time. We are never calling them in when it’s late at night and they’re angry. No one ever says it was “stupid” to be called and they don’t threaten your job for not having the perfect equipment ready to go night and day. There are no loud-mouthed residents angry about being called to the ER. No fight with the floor nurses as we waited to admit a sick patient at 2:00 A.M. and no complaining about what the last shift left us to do. I go home every night from a controlled environment where people appreciate my work and I feel renewed and not depressed. I wouldn’t go back to that miserable hellhole if you gave me twice the money. No one here is angry and that’s worth a lot.” I could see I had opened up a wound. No more probing, just thanks for a great job done. Which this time just happened to be on me, which makes it even sweeter.
• • •
I’ve been thinking about this conversation ever since. In a profession that claims to care, quite frankly we frequently don’t. Doctors are angry about being there on non-prime shifts. Get over it. You signed up for it. The floor nurses are giving our nurses grief about the fact that there are patients to be admitted. I’m not certain, but in every other business, that’s called a good thing. It’s called business. Patients are the reason why we’re there and why we get paid. We’re the only business that continually hates to have more business.
Attending physicians vary all over the map. I have worked with real gentlemen and gentlewomen who are always polite. Yet there are others who believe they are doing us some huge favor by getting off their asses and doing what both hospital bylaws and the Hippocratic Oath require of them, which is to come in, take call, see the patients and be decent human beings about it. It’s no wonder that some of our best people fall into fits of apoplexy and despair. Social justice will never come until there is civil behavior. No event is ever so important that civil discourse can be ignored or abandoned.
Besides being one of the seven deadly sins [and certainly not my favorite] the human discourse about anger has been in existence since the time of the Egyptians. The way to deal with angry patients was first discussed by Imhotep. The Greeks understood it as a sickness, if not a vice. A little provocation is sometimes useful; gets our attention and can mobilize psychological resources and boost determination to accomplish. But there is a sharp difference between moderate provocation and aggression, which can be either of the verbal or physical variety. In our modern world, verbal abuse is much more common but no less damaging.
All of us know those people who are not happy at work. None of us want to work a shift with them. They would be better off if they called in sick – their presence is a negative force to everyone trying to do a good job. The cold shoulder, the half-smile, the total lack of commitment and lack of willingness to take responsibility convey two prominent messages. First, “It’s not my job and why are you bothering me about it?” Second, “When can I retire?” Everything is a debate with them. Their lack of enthusiasm, defeatism and their dispassion are all socially acceptable ways for them to manifest their passive anger. But this passivity can easily give way to more physical manifestations of anger, like bullying and destructive behavior.
In most cases, anger is not a strategy. It gets you nowhere. Why does it exist in the biggest and best hospitals? Because it’s allowed. Essentially, all anger management requires making choices. This is what leadership is all about; there must be consequences for negative acts. Coping strategies and how to put up with anger and its consequences are a must. We need leaders who won’t put up with this sort of unacceptable negative behavior.
Seneca and Galen both wrote about the need to teach children anger control from the days in the crib. They were both aware that such education should not blunt a child’s enthusiasm, nor should it be humiliating or hurtful. But respect for the feeling of others and the rewarding of bad behavior should not be tolerated. Medieval writers up to the time of Francis Bacon debated bringing up whether this was something inborn or an evil humor ingested. The debate continues. A soldier’s control of himself [semper idem] was why the Romans were able to negotiate treaties. Self-discipline, self-control carried them successfully to control the world and has been a hallmark of every successful organization from the time of Imhotep to Henry V.
Some suggestions to those of you who want to happily end careers in emergency medicine, still working in the department. First, be the adult. Everyone will recognize your rational and controlled approach to unruly patients, physicians and staff. Remember that this is a marathon. Careful selection of tone and words set you apart. Second, understand the channels in which real change can be made. Yelling on the phone at a desk clerk at two o’clock in the morning rarely gets anyone admitted faster. But get their names. They have bosses who will not always side with them on these issues. Third, consistency matters. If you expect it out of others, produce it in yourself. Immanuel Kant viewed vicious and uncontrolled anger as the undoing of all great men.
Passion and anger are different. The first one draws you to greatness, the second poisons the soul. In the Book of Genesis, Jacob condemned the anger that had arisen in his sons, Simon and Levy: “Cursed be their anger for it was fierce and wrathful, for it was cruel.” Giovanni Battista Tiepolo depicts the Greek hero Achilles attacking Agamemnon. Funny, this picture looks a lot like what goes on in not only our waiting room but also our staff room. I wonder if Achilles would like to work midnight shift tonight?