I’m Mad as Hell and I’m Not Going to Take It Anymore!
Issue: September/October 2018
Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense
“I’m as mad as hell, and I’m not going to take this anymore!”
— Howard Beale in Network, 1976
If you have never seen the brilliant movie, Network, you should find it and watch it as soon as you can. One of the main characters is Howard Beale, a network news anchor who is slowly spinning into a disastrous emotional breakdown. Peter Finch won an Oscar for the role. In one of the most iconic scenes in American cinema, he exhorts his fellow citizens to rise up and refuse to take “this” anymore: https://youtu. be/AS4aiA17YsM. What does this have to do with emergency medicine? The house of medicine is on fire, and emergency medicine’s room of that house is fully involved. Where are the firemen? Do you think the federal government, state government, hospital administrators, corporate management groups, and parts of organized emergency medicine are spraying water or gasoline on this fire? There are many well-intentioned people working on America’s health care problems, but it has sadly become increasingly difficult to tell which parties are interested in improving the system and which are simply trying to manipulate “reform” for their particular interests.
What should we do to advocate for what is right for our patients and our profession? Please try not to forget that you are in an honorable profession, and not simply a data entry clerk who (for now) cannot be replaced. Frankly, I think most emergency physicians are simply trying to keep their heads down and fly under the radar. This means you type mostly useless data into whichever EMR your hospital has forced on you, while trying to meet the latest and greatest quality measures put in your way, with sprinkles of Dilaudid and oxycodone dropped along the path. On top of this, many emergency physicians are never allowed to know what is billed or collected for their professional services. The corporate management group simply pats you on the head and tells you not to worry that pretty little head over all that billing stuff.
So who cares? While working your next weekend shift and missing your child’s soccer game, will the administrator or contract-holder be worried about your wellbeing? The stroke and sepsis alarms will be going off and you will still have to make sure that your review of systems and medical decision-making components are complete. Your spouse or significant other may or may not understand why you are staying late to complete your charts — off the clock and unpaid. And on your next day off, you will have to respond to a complaint from a chronic pain patient who didn’t feel that you fully appreciated the severity of his pain on his third ED visit of the month. My point is not to make you depressed, but to make you think.
This kind of work environment often leads to feelings of frustration, anger, and burnout. People can burn out and lose their empathy, humanity, and professionalism for reasons unrelated to medicine. However, the current burden of demands and obstacles emergency physicians face should be expected to cause burnout across the whole specialty. What can we do? Can one person or one organization fix such a badly broken system?
The growing burnout prevention and treatment toolbox may be useful to the emergency physicians who can find a wellness path that works for them, and allows them to either embrace their practice situation and feel fulfilled or become content in building a wall between their work and personal lives. Despite some rough patches, I have been able to manage a good work-life balance for myself. I am now 28 years in, and plan to work another five to ten years. But what percentage of emergency physicians have found a healthy path through a work environment in which they have no power, but are still held responsible for results? All the yoga, fishing, jogging, etc. in the world is not enough for many to feel good about their professional lives. The wellbeing of the individual emergency physician should be the main focus of our efforts.
So, the question is what to do — which brings me back to Network. Do you feel like Howard Beale? This is really about the loss of dignity we can feel in today’s health care system. We worked and struggled to reach the top of the mountain, and now many of us feel betrayed.
How should emergency physicians express their discontent? Incoherent rage will accomplish little, but focused righteous anger can be put to good use. Channeling your anger for a useful purpose is often healthy and productive if directed towards a worthy goal. Working towards a goal, especially as part of a team, can help you regain a sense of professional dignity and purpose. We cannot change stroke or sepsis protocols or patient satisfaction surveys overnight, but trying to influence the system for the sake of our patients and ourselves is important. Throwing up our hands in helplessness is the path to burnout, not wellness. Righteous anger contrasts with rage, which usually has the intent to destroy. All of us know emergency physicians filled with unfocused rage. Instead of directing their frustration towards productive change, they mumble and moan and self-destruct.
Feeling isolated and alone while working in your emergency department can be counteracted by being part of a community of like professionals, with similar goals and concerns. I know many emergency physicians who work their shifts, get all their CME online, and never speak to emergency physicians from other practices and environments. In speaking to these isolated emergency physicians, I hear that their emergency department is uniquely dysfunctional, overburdened by administrative requirements, and has the world’s worst patients and medical staff. Of course, this simply isn’t true. We all face similar regulations, metrics, and administrative waste. The sense of community and belonging to a team of professionals is what many are lacking, and despite a healthy home and family life they are unfulfilled professionally and burned out. Sadly, many of us do not feel like we are members of a team, but rather a cog in a slowly turning wheel — and our only remaining goal is not to be crushed by it.
That’s the unhappy reality of American medicine currently, and especially emergency medicine. But don’t give up hope. In my next article I will describe how to restore a sense of belonging and purpose while working as an emergency physician.