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?
My husband has been a paramedic for 23 years, and I feel that he can benefit greatly from this read. The truth is that ANGER attacks anyone who deals in the emergency field
Please congratulate your husband for his service to your community.
I was a paramedic for 10 years, and I quit because I lost empathy for patients. We all felt that our time and training were wasted on patients who do not need two highly skilled professionals. We were angry that we were up at 3:00am, and our patient’s chief complaint was, “My knee has been hurting for two hours.”
I feel that we would have benefited from counseling on how to deal with the emotional aspect of our job.
Such a motivating read!! It’s great to know that we are not alone in this!! Thank you for reminding me that my choice of bring an ER physician is not a crazy one, at all !!
It is a great read as I am contemplating returning to ED work after an, unplanned, 2.5 year sabbatical for medical and personal issues. I find I still have the desire to work a job that provides daily challenges. Right now gearing up the last 8 months in a family-practice oriented urgent Care clinic, while respecting what our colleagues there do, has made me miss the ED very much. After 30 years in clinical medicine, all but 3.5 of them in the ED, I realize my niche is there.
Greg – As always an insightful read. When I was still in the business of teaching and mentoring EM residents I always addressed the anger issue. I told them you cant take care of patients if you are angry, or when you don’t like them. Frequently I would see them walk out of a room frustrated, or hang up the phone agitated. I would council them to look upon patients with compassion, and when that didn’t work pity. Compare the life you have to theirs, it usually worked to diffuse the anger and help them deal with yet another loud, belligerent drunk.
The Florida Board of Medicine in their recently released document on Physician Burnout states that the #1 burned out physician specialty in Florida is Emergency Medicine – 42%. We are not paying attention to the extremely high burn out rate in EM. The large hospital chains – HCA, and others – have instituted a No Wait to see the physician policy in the ER. You may not be aware, but in those ERs, when a patient comes in he is in “Green” status for the first 30 minutes, then “Yellow” status for the next 15 minutes if not seen by the physician/provider, then the patient becomes “Red” status. When the patient becomes Red status, an automatic telephone call goes to the ER nurse director, the physician director, and the hospital administrator.
It is common for the ER Physician to receive a personal call from the hospital administrator inquiring as to the delay in seeing the patient, even while the physician is taking care of a critical patient. It is easy to visualize why EM graduates coming out of residency burn out in 2-3 yrs. We will need to change the name of ABEM to ABEG – American Board of Emergency Gerbils – that come in and start running in the circular cage for a never ending lifespan.
The immediate need to “move the patients” or look for another job is creating havoc in the well being of Emergency Medicine. The poor graduates are coming out of residency programs trained in Ultrasound, but only 30% are utilizing it. Why? because the hospital administrator will want to know why you are “a slow doctor” when I have a perfectly capable ultrasound technician close by.
Some ERs have created a PIT position, Provider In Triage, staffed by a mid-level, whose purpose is to greet the patient and write orders as needed. This “stops the clock” but raises questions about the true meaning of “ER Waiting Time.”
The hospital administrators receive every month a report detailing how many “greens, yellow, and reds” in their ERs, and a comparison where their hospital compares with the other hospitals in their system. The goal is to have the lowest billboard “ER Waiting Time.” We are running the great risk of having a specialty that destroys itself.
Unfortunately, it is difficult for the leaders to speak out against the abuse of Emergency Physicians because they will have to look for another job themselves. Certainly, hospital administrators will not look out for the wellness of Emergency Medicine because it is easy for them to simply “just get another group” to come in, thus continuing the ‘running gerbil syndrome’ noted above.
Some solutions would be, to wait until sufficient number of EM Physicians have retired that can assume leadership roles at a stage of their lives when they no longer depend on contract employment to survive, and can effectively speak out. Increase the awareness of “EMERGENCY PHYSICIAN MALTREATMENT” by disclosing the above practices and how to counter them. Both ABEM and ACEP will have to reassess their roles and how they support the clinical Emergency Physicians that are the back bone of the specialty.
Like Greg, I did my Emergency Medicine Residency when there was only a handful of Residency Programs in this country. I still love Emergency Medicine, but it breaks my heart to see where we are going.
I know my responsibilities and obligations as a physician. What responsibilities and obligations do our patients have? Especially when their care is gratis? Haven’t heard a word about this from anyone in a position of leadership in the EM community. Is the answer that there are no responsibilities and obligations for patients in the ER? Is there any room for the word “no” anymore? Bunch of pie-in-the-sky BS. Look to the well-being of your doctors. No one else can do what they do.
What you mentioned above is exactly why EM doctors have anger. The system under which we work is run by non-medical people who are telling us how to practice medicine. Emergency medicine has gotten away from us and we don’t have the power to change it. It’s not only hospital administrators, it’s also government agencies that write policies and set metrics that are tied to payments to shackle us. Suddenly it’s not about practicing medicines anymore but about playing a game of producing good numbers, metrics, satisfaction scores, compliance with bundles. How can we who invested the best years of our lives teaming in our art not be angry from practice our craft? In a sense, what is happening is disrespectful to our profession.
I worked for Greg Henry’s ER group in the 90:s. Always the consummate gentleman and raconteur, Dr Henry had provided decades of inspiring discourse to countless young and energy physicians. After 60k hours of ER service in Detroit inner city ER’s rural outposts, Indian Reservations, etc. I can tell you what angers me – patients who lie. Let me ask this board a rhetorical question: What sanctions or punishment awaits you if you like to a judge while under oath? Now compare this to the outcome that awaits if you lie to an ER doc. I rest my case.
Greg, always enjoy your articles.
I was an Emergency Physician for 23 years, 17 of those as department chair. Over the years our department became busier and more hectic. Doctors, nurses, and support staff adjusted and we were OK. Administration asked what we needed to function well and gave it to us. Then in the 90s new management began running the hospital. Suddenly the Docs knew nothing and the business guys had all the answers. The bottom line ruled over patient care with cuts in staff and patients waits going up from under an hour to many hours. Everyone became angry. It is hard for nurses and physicians to begin every patient encounter with an angry patient asking: “Do you know how long I have been waiting?” It wears on you and just as in your excellent example, good hard working professionals leave the ER for something more pleasant. I worry about the future of medical care if this trend continues.
The generals in EM have long abandoned the foot soldiers and the shock is that the troops are angry. “it is what it is.”
Wonderful article as always, and as my next shift marches on into the eleventh hour, I will remember your words. What is increasingly challenging is unrealistic patient/family expectations and the anger that spews from families not only on ED staff, but in the written and verbal complaints to the “patient advocate” that filters through the “quality management” process. Case in point: An operative open reduction of a nasty fracture (no vascular or neurologic compromise, mind you) and it took 4-6 hours on a Saturday night to assemble surgeon, anesthesiologist, complete OR team. I’d say we were doing great, but a parent is angry about the delay. The era of snap my fingers and receive instant, perfect, inexpensive (or free?) care is now upon us, and my angry patients have taught me yet another skill: Manage patient expectations.
I left the ER after 17 years and went to Urgent Care in the same system. What a huge difference! I have rediscovered the joy of practicing medicine. The hours are better, the patients are appreciative and…no one is angry. When I apologize to someone for their having to wait on a busy shift they say things like, “Oh, that’s okay, we saw all the people who checked in before us and we knew it was busy”. EVERY SHIFT I have at least one person say, “Thank you for your time, I really appreciate it”. What?! I miss critical care, I miss the procedures, miss the camaraderie unique to the ER and I wouldn’t trade my time there…but I also wouldn’t go back. This article was spot on. Thank you for writing it.
I have a mountain of respect for Dr. Henry so I want to make a contrarian point with as much grace as possible. Sure ER folks chose a business that’s always open so hard to argue about the odd hours. However, none signed up for the frustration that comes with unsupportive administrators/ medical staff or increasing hurdles without any evidence to support their benefit (i.e. certain core measures, satisfaction scores, etc.).
What drives the growth of anger is the constant stick and lack of carrot. That’s why your former nurse colleague said you couldn’t pay her enough to go back. She was finally getting appreciation, recognition, less stress not mounting hurdles with less resources to meet increasing demands.
Saying there should be consequences for the development of frustration in an environment that often breeds contempt, seems like you’re proving the point about administrators lack of understanding both of the root cause and any effective means to create an environment of peace and happiness. There used to be a far side comic that said something to the effect of “Beatings will continue until morale improves.” Sadly, that has become the way of life for many in the medical community. I think we can all agree we wish it wasn’t that way but it is more often than not. It seems hard to envision a scenario in which more punishment will change that culture for the better.
With all of the visionaries doing research to improve so many aspects of what we do, one would think since this is such a pervasive issue, someone would make solving this problem a priority for the sake of not only our specialty but so many who participate in some facet of our profession. Perhaps Dr. Henry could lend his passion and influence to champion the cause as if his legacy wasn’t already impressive enough.
Spot on, and it’s not only in the ER, it’s in the OR, on the floors, in the units. Drives away the best doctors, nurses and staff,
As alway, Dr Henry you are a great writer and a great speaker.
After working in the ER for almost 17 years, I am now working as an outpatient family medicine physician. Colleagues are not attacking me for patient care by questioning my education, brain capacity and ability to walk and chew gum at the same time. Patients, for the most part, are friendly and interested in learning more about their healthcare. We actually get an entire hour for lunch! That makes me very happy! The nursing and medical tech team are courteous, interactive and nice. We endured 2 new computer systems and the, frankly, up front statements from administration that what really matters is the computer and clicking the right buttons (I look at my computer much more than I look at my patients). I am under no illusion that I am in charge. I am another worker bee who is told to jump, and I am to reply “How high”? But the environment is calm, quiet and most days are easy. I still almost jump out of my chair if the PA system comes on and the operators voice begins. I still find a general intensity and gearing up happening to me when I travel to work and enter the building. That is easing up some, but will probably always be part of me. Who can say in a second they can become mentally and physically reading for a mass trauma (you know what I mean!). Last week I was actually looking out the window from my office in my comfy chair, and thinking the day was going so slow! Yet I get to leave at the end of the day without my brain in a fog, my body pushed beyond fatigue and my soul not torn to shreds. So, I will always wish for and miss the ER. Everyone still pushing on, our thoughts are with you!
It is hard for me to admit this but this started really affecting me after about 20 years in practice. I started wanting to really isolate when I got home from shifts, which was easier with my kids grown. When your kids are there you obviously just keep going and doing social things. But I felt like either everyone wanted something from me, or they were upset with me, those were the two options at work. Also though I never lost my temper at work, I would get unreasonably upset with silly things like telemarketers etc.
The way I improved this was to take a part time position researching new medical issues and writing about them, which gave me some pleasant, cooperative folks to work with and an intellectual pursuit, and also I started walking for over an hour a day with my spouse or if he can’t go I walk with headphones/music.
One (sort of) funny story, I had admitted a patient about two years ago, a lovely lady with end-stage metastatic cancer, who I admitted for a bowel obstruction. She was very painful. I called the Surgery Intern, who came down and started yelling at me in front of patients and staff for calling him without “removing her colostomy bag and finger dilating the ostomy”. He would not stop yelling and would not listen at all, so I had security remove him from the ER. He ended up getting in some big you-know-what over that, bet he won’t do that again. But that kind of stuff was driving me nuts.
Such a timely article. A neighbor accidentally parked his BMW in my mother in law’s garage at 2AM the other day…at over 100mph…and the police and fire department was constantly commenting on how calm she was and “why aren’t you angry?” She is a remarkable woman and I complemented her on this. I tend to also be a person who controls my emotions in situations…as all we ER doctors must, so I really relate with her on this issue. Whenever I’m talking to folks about anger, I always am reminded of the movie, “MYSTERY MEN”. Ben Stiller’s character has the super power of being able to get really angry…and he never accomplishes anything with it…but he gets really mad. I think it’s a perfect example
Interesting to read. I am a very experienced RN. I have 37 years experience as an RN. I have not worked in the E.D. but rather ICU, NICU and
PACU. My experience with physicians is the same. I work with some great surgeons and anesthesiologists who are not angry when they are called regarding their patient, however, there are far too many who can’t be civil if they are contacted for any problem that arises…even during DAYTIME hours. I am articulate, intelligent, and very knowledgeable. Doesn’t make any difference. If they are annoyed for being “bothered,” regardless of the reason, I receive a raised voice and far too often, a refusal to “help” to solve any problem with their patient. I don’t make frivolous calls. I call for patient safety issues, when I don’t have orders, when the patient is having problems. Yet I am not surprised with certain physicians when I am yelled at, cursed at, treated condescendingly, told to fix the problem, etc. It doesn’t seem to make any difference with those doctors. Fortunately for my patients, I am a patient advocate. I am there to protect them and see that they are safe, cared for. Too bad their physicians don’t feel the same way.
And I find it humorous that I know a particular urologist, who, at 2 AM when their patient was arriving to the PACU, actually stated “I didn’t sign up for this.” Hmmm…I wonder what they thought going into surgery really meant….!
Hi Greg Great coverage of anger: ‘The ancients said all.’ Einstein
“The only disease.” Heraclitus. Plus – writing book on spiritual medicine – the history. Your Imhotep quote ruins my observation he has been forgotten by everyone.
Sic transit gloria mundi
Anger management is good for everyone and specially for health care professionals who need to focus energy into patient care as best as possible, whatever area of medicine is practiced. Thanks to the ER doctor on the front lines and hope there are satisfying career avenues for all in the ER when they have had enough and need to step down.
This article really strikes home. I have lived by the motto “In the end only kindness matters.”
Thanks for sharing about Anger and the Undoing of Great Physicians