Common Sense

Perception is Everything


Issue: July/August 2021

Author: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM
President, AAEM

One of the principles I learned when, prior to medical school, I trained to be a psychotherapist is that when individuals are relating events, there is no objective truth. Each person will tell what happened through the lens of his own experience, based on her own perception, from his own vantage point, and may even see things differently years later when new life events have been experienced. How we experience things IS our reality, and throughout history, outside influences have impacted how we create our reality. As early as the 1920s Edward L. Bernays, “the father of public relations,” began what we now refer to as “spin.” His most nefarious campaigns included convincing women that smoking equates with female liberation and as history altering as working with the notorious United Fruit Company to coopt the CIA into taking down the democratically elected president of Guatemala based on an allegation that he had communist leanings and was a threat to Christian morals. In his book Propaganda (1928), Bernays stated that the public is composed of irrational individuals who follow “herd instinct” so that “crowd psychology” can be used to control their behavior in ways that governments, advertisers, and manufacturers find advantageous. While the characterization of the public is insulting and simplistic, the principles of propaganda have been shown to be effective. Over decades, propaganda and spin have changed little, except that in the era of social media, we say things more succinctly. AAEM member Dr. Andrew Pickens, who holds an MD, a JD, and an MBA, told me how they say it in MBA programs: Perception is Everything. It is how we perceive things, or how we are led to perceive things by how they are spun, that creates our reality.

But while objective truth may not be accessible in our experiences, there is objective truth in the universe. Smoking causes cancer. Nations have the right to a democratically elected government of their choosing. Genocide is evil. Nurse practitioners have far less classroom education in pathology, physiology, and pharmacology, and far less clinical training than physicians. Vaccines prevent disease. While we all know these facts to be objective truth, we have watched the “experts” and the media spin these facts in such a way as to make acceptable to the public that which is sensational, sells news, or elicits the response that the messenger desires. In many cases, the perceptions that are created do not match reality. “Oh, what a tangled web we weave, when first we practice to deceive!” (Sir Walter Scott, in his poem Marmion, 1808) And the web is so tangled that the American public cannot find its way out. The American public is suffering because of false perceptions. Let’s consider the issue of masks. Masks prevent disease. It has been well proven and it makes perfect sense. A barrier that prevents the exchange of body fluids protects against diseases transmitted by exposure to body fluids. Yet some of our government officials and media pundits have convinced citizens that masking is a violation of civil rights or constitutional freedoms, and that masking should be related to our political affiliation. Similar spins have been put on vaccines: vaccines are not actually FDA approved and they don’t actually prevent disease since many people who were vaccinated have contracted COVID.1 So, if the vaccine isn’t even approved and it doesn’t prevent the disease it was designed to prevent, why should I get the vaccine? What is not being put out there is the fact that we are seeing a second wave pandemic that is a pandemic of the unvaccinated. These are the people we are intubating, hospitalizing, coding, and pronouncing. A small percentage of the vaccinated, less than 1% according to an August 2 CNN report of a study by the Kaiser Family Foundation, do get COVID, but they don’t get intubated and they don’t die. For most of them, having COVID means staying home feeling miserable and exhausted, coughing and quarantining, and then going on with their lives.

Another popular perception put out to the American public is that of “providers” as a group of health care professionals who are equally capable and knowledgeable to care for them. Nurse practitioners (NPs) spin themselves as having “the heart of a nurse and brain of a doctor.” First of all, doctors have a lot of heart, especially emergency physicians. But perception is everything and we don’t make the public aware of the amount of advocacy we do, the extent to which we practice social medicine, and the factors we consider when deciding who gets admitted and who goes home or who gets an injectable antibiotic and who gets the prescription. Second, no one is questioning the quality of a nurse’s brain. What we question is the degree of education and clinical training that brain gets. When I recently lobbied legislators regarding the bills for independent practice of NPs and physician assistants (PAs) in Louisiana, I was disturbed by the lack of knowledge that legislators have about the education and training of NPs and PAs compared to physicians. These legislators are responsible for deciding who will care for America’s patient population and in what roles and yet, they do not know the facts. Instead, they respond to spin about NPs needing independent practice so that they can go into rural areas and care for those who physicians allegedly choose not to care for (and we know that they are as unlikely as physicians to choose to go to rural areas) and spin about how they have the heart of a nurse and the brain of a doctor. PAs put forth that they are not endorsing independent practice but rather “Optimal Team Practice.” They hold that expecting an individual physician to supervise an individual PA is “not being a good team member,” and put out this spin on their website:

The reality is that, in today’s healthcare environment, there is no such thing as “independent practice.” Gone are the days of the solo practitioner, working completely alone. Just like physicians, PAs will continue to collaborate with, consult with, and refer patients to other healthcare providers whenever the patient’s condition falls outside of their education, training, and experience. The PA profession’s commitment to team practice is powerful. The PA and physician who work together get to keep all the benefits of the team without the legal risks and administrative burdens that agreements entail. In addition, employers will have access to a wider range of providers and won’t have to file unnecessary administrative burden. Everyone wins.2

Nice spin to say that “Everyone wins.” The fact is that the health care disparities that we know exist today and that were deemed “unacceptable” by the Institute of Medicine Report in 2003 will only worsen when those who are Black, Brown, poor, rural, uninsured, underinsured, don’t speak English, don’t have a choice of “provider,” or don’t know the difference between a physician and an NP or PA are forced to receive substandard care. So, no, everyone does not win. Corporations may win. PAs and NPs may win. Hospital administrators may win. And MILLIONS of patients will not win. Why do I use the term “substandard care”? Because by AAEM’s definition, a specialist in EM is a physician certified by ABEM or ABOEM, and, according to AAEM’s Mission Statement, EVERY PATIENT with an emergency condition should have access to the care of a specialist in EM. We do not support a system where any patient receives less than optimal care. The corporate practice of medicine is another area where spin is used to alter perception. In a recent Emergency Physicians Monthly article, a Missouri court ruled against EmCare in a wrongful termination lawsuit and explained their spin: 

EmCare is a subsidiary of Envision Healthcare, which is owned by venture capital group KKR. According to the appellate court opinion, EmCare creates different legal entities for each state and/or location it provides emergency medical services so that it can comply with laws prohibiting for-profit corporations or publicly traded companies from owning physician practice groups. EmCare then assigns a physician “owner” to these legal entities that manage many day-to-day operations and staffing issues.3

So, perceptions are created that a physician owns the group. This makes it all good for EmCare to practice medicine. The article was telling. It highlighted statements of a hospital CEO stating that a physician was taken off the schedule “because he wasn’t being supportive” of hospital policy. It went on to state that the appellate court detailed evidence “showing how EmCare admitted that its staffing decisions were ‘financially motivated.’” EP Monthly is a publication for physicians. Why is this article not in the New York Times or being broadcast on CNN? The American public believes in private equity, startups, and the sleek image of brands. Brands have money. Advertising agencies have money. CMGs have money. AAEM does not. Despite this, I am hopeful that what is right will prevail but it cannot do so in a vacuum. We need to change the nation’s perception.

If perception is everything, we need to take advantage of the American public’s perception of emergency physicians. They see us as their heroes and this is NOT the result of spin. This is the result of the fact that we stand for our patients. When other doctors closed their clinics and offices, we changed nothing. We are there for every patient, every time, 24/7/365. Before the COVID vaccine existed, before anyone even knew what we were dealing with in SARS-CoV-2, we showed up for our patients. We were there, we diagnosed them, reassured the mildly ill, admitted the moderately ill, intubated the severely ill. We comforted their relatives. We taught them how to prevent the spread. We lobbied for free and wide-spread testing. We helped legislators understand that testing patients without requiring ID was a public health necessity. We showed up at testing sites. We educated the public using every form of media available. We got shots in arms, and now, even when it jeopardizes our own health and that of our families, we continue to diagnose, treat, and intubate those who refuse to be vaccinated and who refuse to wear masks. We have changed nothing. We still don’t judge our patients for their smoking, excessive alcohol use, gun violence, inappropriate drug use, failure to wear seatbelts, failure to wear masks or be vaccinated. We still fight for patient safety, the right of every patient with an emergency to be cared for by a board certified emergency physician, and the right of every patient to have a physician whose only concern is doing the right thing for the patient, not whether a corporation will fire him for doing the right thing for the patient. If perception is everything, we must step up and align perception with fact. The Board of Directors is putting our energy behind marketing the message of AAEM to the American public and to gaining access to the legislators who can impact how health care is practiced in this country. We have issued an RFP for a company skilled in revising our website and our social media presence. We are interviewing for a staff member who will be highly skilled in media communications and web management. Perception is everything. We are the Champion of the Emergency Physician and that makes us the Champion of the Emergency Patient. The country needs to know who we are, and that we stand for optimal and equitable treatment for all people at all times. To do this, the EP must have workplace fairness so that she can concern herself only with providing the very best medical care for every patient. I am challenging you to join your Board in Washington DC on October 19-20th to educate our legislators and advocate for workplace fairness and patient safety. I am challenging you to join your Board in altering the perception of the American public about CMGs and non-physician health care professionals. I am challenging you to bring your ideas, suggestions, and strategies to your Board and to your President. PERCEPTION IS EVERYTHING. We must alter perception to align with fact.

References
1. As of writing, none of the available COVID-19 vaccines were fully FDA approved.
2. Optimal Team Practice: What Is Optimal Team Practice?” Available online at: https://www.aapa.org/advocacy-central/optimal-team-practice/#accordion__panel--5--is-optimal-team-practice-the-same-as-independent-practice
3. “$26M Judgment Against EmCare in Wrongful Termination Lawsuit.” Available online at: https://epmonthly.com/article/26m-judgment-against-emcare-in-wrongful-termination-lawsuit/

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