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Thursday, February 18, 2016

Guido Sarducci, where are you?

Sometimes the things I've got to do are the cause of sleepless nights and enough daytime stress to ruin my week.

Just this week, I had to let one of my colleagues go. And what made things worse was that he 's a really nice guy. I kept telling myself that if he were a real obnoxious dirtbag, things would be easier. But then I was reminded of other occasions where I've had to let go of some other folks who were either not so nice, or truly incompetent, and still it was never easy. It seems that I'm just not one of those Donald Trump or Godfather types, who have no compunction about telling someone that they're fired, or to just let Guido take care of it.

And this whole thing got me thinking again about medicine, and what it has become. Back when I first went into the practice of medicine (in 1981), I remember that I was astonished, having just come from a University training program, that I was respected, just by being a doctor. I will admit, that I did go through a long program of training, and I was now 30 years old. But I was actually incredulous that nurses, lab techs, X-ray techs, and administrators (there were only one or two per hospital in those days) actually listened to what I had to say, and trusted my judgment in medical matters. This had not been true of residency at all, where we were the butt of nursing jokes, and generally looked down upon by any and all persons in the hospital setting, and especially by the attending physicians, who would make their thrice weekly appearances on the wards. There existed a hierarchy of respect, where the attending physicians were the top dogs, and all the other persons were scrambling about in their respective niches, trying to establish themselves. And at the bottom of that pile of humanity were the very lowly residents and interns.

Then when I stepped out into the world of medicine outside of the University, I was an attending physician, suddenly on top of the pile. It took some time for me to adjust.

But what about today? How has that all changed, and why? Now at the top of the hierarchy sit the CEO, the CFO, the CNO and the other occupants of the C-suite. Below them are the "midlevel managers," which include the directors of Quality, Safety, Coding, Billing, Medical records, Computer systems, and the innumerable persons whose job it is to determine whether the actions of physicians meet national standards of quality. Below them are the nurses, who may not realize it (based on salaries), but whose position is that above doctors. And I would note that nurses have their own hierarchy. With the ICU nurses on top, then the OR and ER nurses, and the run-of-the-mill floor nurses.

Now, down near the bottom are the doctors - there among the dietary staff, the environmental (housekeeping) crew, the maintenance staff, and the secretarial staff. And as physicians, we typically have to answer to all those above us in this mad food chain which we call hospital medicine. Nothing really changed as far as physicians themselves (other than residencies have now become too bland), but the world of medicine has changed dramatically. Gone are the days when a physician could just "hang up a shingle" and begin the practice of medicine. Faced with seemingly endless protocols for certain diagnostic entities, as well as the increasing pressure to produce a record of unyielding and unreadable stuff on every patient admitted, which is really only intelligible to medical record clerks and lawyers; physicians have become another cog in this great wheel of managed, scrutinized and frustrating "medical care."

So lies my dilemma. What do you do with a physician who has been deemed (mostly by the nursing staff) to be practicing medicine that is "not up to par?" It seems that there is no wiggle room any more. A physician can no longer have a "bad day." He can no longer be too tired, too stressed, or too fed up with all this. He must practice only elite medicine, be perpetually up, permanently smiling, and pleasant in the extreme.

I do have some thoughts on the origin of all this, but that will be for a later blog post. Right now
I'm looking for Guido Sarducci. I've got a task or two for him to carry out...


  1. I've worked in a hospital before and what I noticed was that everyone was overworked and stressed and that, among the "support players" you had those that really cared and those who were just there to collect a paycheck. It was definitely frustrating. I only knew a few doctors and a new nurses, my main interactions were with administration.

    1. It's definitely a different world, and it has become a world of instability. I think it's fortunate that I only have but a few years to make a difference before I retire - that's when I get to quit my day job...