Dr. Gerard Rover MD

How on earth have we stopped wondering how doctors become bitches? having done my share of ridiculous summer jobs, I can confidently say – in most lines of work – bitches get fired. Now at loss for a proper male version of “bitch” I will simply refer to the males as bitches too.

Apparently our institutions condone bitches – so in order to understand our own failure, there are two questions to ask ourselves. How did we create the bitches, and how do we get to not firing them.

1. We create bitches by crediting certainness over uncertainness. We ask our doctors to present without any hesitation, we ask them to be confident. We ask them rule out the possibility that they could be wrong. We credit doctors for giving straight orders in a setting of urgency or emergency. We teach them to be clear and crisp and make sure nobody second guesses us.
2. We forget to fire them because we live in an imaginary world where we created the idea that we cannot live without bitches. We will say over and over again ” sure he is a bitch, but boy can he do a heart transplant”. So what we are saying is that we as a society accept bitches around us because they are the best.

So why do I then as a more mature doctor think it is wise to show uncertainty and use that in your medical decision making. Think ahead – what if I am wrong. Share your thoughts with patients, show them you are not 100% sure and that we need a plan for when we are wrong. That is why we have follow up, discharge instructions. Patients benefit from us not lying to their faces and doctors grow to be more content with decision making.

So how do we fire bitches? Well it goes without saying it starts by not hiring them, and take it a step further; selecting nice people for your training program.  But the real deal is management. A hospital director that fires a heart surgeon because he is a bitch would make headlines. Being a bitch should be in the contract: subsection 12b. “If you are a bitch, you can be fired”.

So who tells management why we do not want bitches in our hospitals? Who tells them that bitches make for sad patients, bad outcomes, concerning problems for residency programs, highly likely worse mortality rates…… It has to be you. Because you are not a bitch… right?

Share if you are not a bitch #nobitchesinmyhospital

So as I was attending this conference on ED crowding an old thought reentered my head. What if crowding cannot be changed, what if all the efforts we put in making a system work more efficient then it has been for ages are in vain, what if human effort to improve what is already set in stone for decades proves to be futile. What if that idea, terrifying as it is, is only slightly worse then the concept that the system could very well be improved upon if only the ED docs would work harder.

Yet, there is one thing that can be done. What if we as patronising doctos let go if the idea of the patient on the bed. Why do we put people on beds? Do you want to lie on a bed when you are sick?  What do you do at home if you are sick. Right, there is sick and sick. Most of the times, you actually want to sit somewhere comfortable, watching old reruns of cheers while all you need to do for water or tea is reaching out for it. And! the cookiejar besides the teapot. Sure if you in septic shock, you might want to lie down for a bit.

Why do make our patients lie down for more then the two minutes it takes to ultrasound them or examine their bellies? Do we feel better when a patient is supine? It kind of controls stuff right? Patients that lie down don’t come to your desk to ask questions. I will tell you why we lie patients down on a bed; the waiting room is to uncomfortable. No way you are going to say to an elderely lady, please sit on that wooden chair in the waiting room again opposit from the blood spitting alcoholic, and next to the screaming todlers. We don’t. But what if….

What if the waiting room was cozy, there were televisions and ipads, there was coffee tea and biscuits. What if you had some privacy there, or could invite a visitor. How would you feel telling the 30 year old headache patient, thank you for examining you, The lab results will be back in 50 minutes, why dont you head to the lounge, grap a cup of tea and watch some old Cheers episodes. Wouldn’t that make you feel better? Wouldn’t that make us all feel better? Wouldn’t that dramatically increase the amounts of available beds.

So are we able to make a system, that has been set in stone for decades, more efficient? Maybe not. But we can build a new one. Lets build a new one.

For whatever reason acute care doctors got themselves trapped in an impossible dogma. With no way out, with no sign of any emergency escape, we have let ourselves be stranded in an impossible world where ignorant junior doctors feel comfortable. Allow me to explain.

As junior doctors have been struggeling with delivering good healthcare to the acute ill, we have dogmatised the idea of the golden hour. Save lifes, do it right now, meaning get expert help now. Don’t fuck around, call your supervisor, even if that is me. Now that we kind of got this one sorted the idea went viral. Everything needs to be now, STAT. Faster, faster, Fastest…

The other day we saw this kid, fell of some stairs and is doing fine. Is playing in his mommy’s lap. He was triaged to be seen urgently and after carefull evaluation we found there was not a single injury in sight. Proceeding cautiously we managed to get some imaging that was fine. Mother was fine. Kid was fine. healthcare done. Wanting to admit the patient for some observation a junior doctor from the admitting service rolls in, exited, pupils dilated and obviously on drugs (by that I mean bitchslapped to often by her supervisors). There was no excuse for our behaviour, obviously we slipped. Because My Oh My, had we let the golden hour pass.

Little kid doctors out there, let me rephrase the golden hour again, for once and for all. The hour is a concept, not a real thing. You can not feel it, touch it, nor measure it. The golden hour has not passed after 60 minutes, nor will it need to last that long. Being kind and kind to your patient, weighing in reality, humanity is priceless. Looking at a clock is what was thought in kindergarten.

Personally I like to scream. Loud and long, high pitched and scary. I like it when people are startled and for a minute interrupt what they were doing. I love it when people around me start to tremble a bit so they have a hard time finishing whatever time critical and highly complex task they were doing at that moment. I enjoy seeing the effects of adrenaline on precision and appreciation of perplexing situations.

That is why i scream when in a roller coaster, or when having sex. That is why I grunt when eating chocolate or choosing the best iphone from the web.

Some people have interesting personality traits. We regard them as daring, or intelligent. We sometimes give them credits as “he is too smart to interact normally” or “he has been in the OR all night”. In healthcare we have stopped wondering why people behave in a certain way because there have been, always, morons among us. It cannot be that they simply are ill equipped for resus right?

I walked into Play-Resus yesterday and found a trauma surgeon – roleplaying a teamcoach – stopping in the middle of a scenario to confront a junior doctor that, without any training whatsoever was put in the position of being teamleader in a rough trauma case. He stated, without hesitation: “I am going to give this to you as loud as I can so you will never forget: YOU DID IT ALL WRONG!”  And then went on roleplaying his part of teamcoach.

Screaming is fun, it is exhilarating, in fact I like to scream at my wife, at my kids and at the referee during soccer games. However, neither my wife, nor my kids, let alone the referee ever did any beter after my interventions. Kind of makes you think….

Oh dear. I realise that nobody wants to read this, but i just need to write it down. If not, hatred will consume me from the inside out. A void will start to appear in me, where I now keep my other emotions and slowly and slowly there will be nothing else but a thorough feeling of pain, misery and sorrow. Hospital administration is the root of all fear, it centres deeply felt distress and most importantly, administrators are plain silly. Allow me to elaborate.

For all this time that I have been roaming the hospital floor and about 90% of that time was spent fortunately in the ED, I have seen how health care works. It is nice nurses that hold your hand while you vomit and it is doctors that prescribe antibiotics knowing perfectly well that time will heal, or it may not. It is simply not ours to control. We guide, we try… we help and we soothe. Medicine cannot be controlled. Not only do therapies not always work, patients don’t seem particularly keen on following instructions. Other stuff turns out to be more important (who will feed my dog when I am in) and clinical care is not much better then your mother-in-law walking in on you every once in a while when you don’t want her there.

Yet administrators tend to think that care can be directed to an extend that actual numbers make a difference. A directive should not only be followed but should be measured and then, when the numbers don’t add up, more  measuring of the data needs to be done. Where medicine can only be measured at the end (the patient survived, or more likely – had a pretty good feeling about their stay), we try to calculate in between scores.

And, the obvious answer to all of this, empowering nurses, empowering doctors, empowering patients to say what they need, what they want. To make them feel in control and more important in charge seems to be at the bottom of the list of administration priorities. Why is that? Why does administration ask doctors if they met their targets in stead of asking them what they need to deliver better care.

I ask them, I beg them to give them what I need. In no particular order: Decent medium care facilities in all hospitals. Social workers that have full responsibility, sexy nurses and patient empowerment programs.

if only one can be achieved then for gods sake hire the sexy nurses. That usually makes social workers more likely to roam the ward and will somehow empower patients anyway.

So what has changed over the years, well first of all the nurses. There used to be a time when as I was walking in the room, my white coat dragging the wind, my curls slightly propelled forward, the room changed temperature.

These days, not helped by the fact that hospital administration is so darn cheap and comfortable climate control obviously isn’t, I get coldhearted blank stares. Nobody looks up. Nobody bows. Nobody says Hi dr. Rover. Now from my colleagues I can understand, but the nurses are still the same. They are still 27, they still just came back from whatever music festival they just visited, they still are madly in love with the wrong guy and at the same time secretly hoping a nice curly doctor enters the room. What happened to me? Did I overdo my youth and everybody remembers? Do the nurses keep a log from days long past to make sure no information on the old staff disappears from public memory?

Somewhere between now and thirty years ago i noticed nurses not being impressed by me anymore. If secret glances were seen they went to my junior colleagues or even worse, residents. The whole implicit thing that as a supervising consultant you would have automatic sex appeal kind of slipped away. And where does that leave me. Sure I am in charge of stuff, but if nobody believes me anymore how do I hold up?

And then it dawned on me. It is not me that is turning grey and crumbled, its them that became younger  then nurses were supposed to be.  Some asshole manager probably lowered the minimum entry age for nursing school without giving us notice.  They are, as it turns out, no longer 27 but 23. They did not just come back from a music festival but from swimming lessons and they are not secretly hoping a nice curly doctor enters the room because they have been too busy doing their homework.

And thus I rest here, in my same old hospital, waiting for the nurses to mature so they will, once and for all, see the beauty in me…

So everybody finding me was hoping for a fluffy little blue monster? Well guess  again, I am a fluffy little blue monster with a scalpel! No just kidding. My name is Gerard Rover, my friends – well, my colleagues call me dr. Grover. But then again, who am I kidding. They usually refer to me as coldhearted basterd.

I am working as an attending emergency medicine physician in a hospital that has been almost shut down for decades and will be just that for decades to come. Meanwhile I am stuck here. Since none of the nurses can hear my stories about how things used to be no longer,  I decided to trash the internet with it. Good luck