Sep 28, 2021
I swear by Plutus a Cornucopia and Demeter and Persephone and last but not least Priapus and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and covenant:
To hold he (or she) who has taught me this art as equal to my coffers and to live my life in domination of him, and if he is in need of money to give him none of mine, and to regard his offspring as equally undeserving in materialistic lineage and to teach them nothing of this cruel art - even if they desire to learn it - except perhaps for a handsome fee or dowry; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no other law-- too bad, so sad, I will see you in court else this burden will be taken up by those less successful than myself, but no not me.
I will apply dietetic measures for the benefit of the shareholder at the expense of the sick according to my ability and judgment; I will keep them well fed and well compensated even if this widens inequality.
I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect—first, who knows which drugs are deadly? Also then who will pay, who will buy? Similarly I will not give to a woman an abortive remedy. In purity and selfishness I will guard my life and my coffers and my dividends.
I will not use the knife not even on sufferers from bankruptcy, but will withdraw in favor of such losers as are engaged in this work.
Whatever houses I may visit, I will come for the benefit of the board, remaining free of all intentional injustice, but creating victims to loads of meh injustice, of all mischief or carelessness, and in particular of sexual relations with both female and male persons, whomever I can intimidate or assault and not get caught. What I may see or hear in the course of your mistreatment or even outside of the treatment will be considered in regard to the life of real men, which on no account should be wasted on a broad. I will keep to myself, except when bragging, otherwise holding such things shameful to be spoken about, all the easier to bury the evidence.
If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with bonuses above all men for all time to come; if I transgress it and treat the populace rightly, may the opposite of all this be my lot: no bonus, threat of fire, and I, too, will be unable to see a physician.
- S. Sham
Sep 22, 2021
Thank you so much for the work that you are doing regarding the extremely subpar Nurse Practitioner training. I graduated from an FNP program in 2003 from a respected nursing school in New York City. I Immediately suspected that something was terribly wrong with the training. I received my undergrad at the same university and the assessment, pathophysiology, and pharmacology classes were basically the same course as in nursing school with "advanced" added to a the syllabus. The ball was not at all moved forward. The exams were take-home. I was shocked at the attitude of the professors in that one actually said that primary care physician were "over-educated" for what they do. It was as if the NP training was an alternative to MD training, much like DO training. I worked full time during my two years in school in the ER, took vacations, etc. The schooling hardly interfered with my life. It seemed that everyone received an "A" It was as if grad school was a just a hobby. My clinicals, mercifully assigned by the school, were scattershot, the best being the one hundred hours of woman's health with an MD. In many of the clinicals, I actually felt that the NPs did not have a complete grasp and were "faking it until making it." Good plan in a job such as fashion design, but disturbing and dangerous in patient care.
It was shocking what the program did not teach or relegated to just an afternoon seminar—lab interpretation beyond the basics, X-rays, EKGs, antibiotics, even how to treat a patient with co-morbidities. I learned massively more medical information as an emergency room registered nurse. My graduating class was small at the time, only fifteen. Now the same school is graduating nearly a hundred, flooding the market year after year.
I suppose patient care is so easy, that anyone can do it, and they are. I wisely decided that I will NEVER work as an NP in direct patient care. The most frightening NP is one who doesn't know what they don't know, and I don't want to be that kind of NP. The graduate degree did open doors for nurse research and nurse coordinator jobs.
I think that there is more trouble on the horizon. The family nurse practitioner now is rather out of fashion, being replaced with acute care nurse practitioner. I know many new and arrogant, nurses that are in that program with the deluded goal, of becoming a "hospitalist". If I wished to switch to acute care, or psych., it would only be three semesters in a certificate program.
Trust me, many, if not the majority of NPs feel the same way as I do. I considered getting a doctorate so I could teach, but decided that I do not want any part of the broken system. The work that you are doing will actually save the profession from imploding, which it will if it continues down this path. I think it needs to be completely dismantled and rebuilt. I am now getting my masters in an entirely different field, one that has some modicum of standards.
Sep 15, 2021
An ox. That’s my mother-in-law. Doesn’t miss a day at the gym. Ever.
Monday. She goes to the gym and gets to work on the treadmill. A few minutes in she gets chest pain so she decides to stop. She decides to see if the bike goes any better. It does not and again, she feels the tightness in her chest. Maybe the row machine? Nope. Chest pain. Hmm. She decides to sleep on it.
Tuesday, she skips the gym. Like I said—ever. Mom-in-law never left the couch on Tuesday, instead she zoned out watching reruns of Frasier.
Wednesday, she’s back at the gym. Same damn chest pain. She doesn’t tell anyone of course and staggers her way out to her car where she calls her daughter Pam.
Her other daughter, the one I’m not married to.
“Pam, I’m not very happy right now.” Mom-in-law said.
“Why, what do you mean?”
“I couldn’t exercise again today.”
“What do you mean again? I don’t like how this begins.” Mom-in-law tells her the story of Monday, how she could not continue to exercise, goes on a sidebar about her favorite Frasier episode about sibling rivalry, finally tells Pam about Wednesdays chest pain and Pam takes her to the urgent care. It doesn’t matter how many times I remind Pam; she refuses to stop going to urgent cares—she thinks I’m an idiot. At the urgent care, the EKG is read by the computer as normal. Mom-in-law is told that this is angina by the nurse practitioner. They asked to speak to the supervising physician. Their request was refused. Instead, the urgent care arranged an appointment for her with cardiology in—three fricking weeks! Sent her home and told her exercise is okay, but! If her chest gets tight, go ahead and stop. They sent her home to die.
With chest pain off and on, mom in law toughed it out through the night. The next day, I finally hear this story from sis-in-law, Pam, and I speed mom in law in my Camry straight to the emergency room, where the EKG is reviewed and unchanged; and ischemic. Troponin is three. Cath lab finds a ninety-nine percent lesion of her left anterior descending artery. She receives two stents. She recovers uneventfully, thank God.
A nonphysician literally sent her home to die and could not recognize a failed stress test. God help America. What if mom in law had not had an actual physician looking out for her? She would be dead and my wife would be devastated. Because an urgent care pretended it could handle chest pain and interpret EKGs.
I have taken to repetition to my Facebook and Twitter and other #SoMe, repeating my warning: beware the nonphysician, they don’t know what they don’t know. And most Americans don’t know what they don’t know either.
- S. Sham
Sep 3, 2021
“Dr. Sham, can I talk to you for a second?” It was my third time working with this young physician assistant. “I’m not sure who else to ask, but this just doesn’t feel right.” This is what I get for being the coolest attending, I guess.
“Sure, what’s up?”
“I’m not sure what to do.” She started shaking. “I was pulled into my director’s office at [the sister hospital]. You know him, right?” Oh, that’s why. I knew it couldn’t be the “cool” thing.
“You mean Kennedy?” She nodded. “Okay, Dr. Kennedy, great guy. What did he do?” I braced myself.
“Apparently, we are being told by corporate, and Dr. Kennedy told me to my face, that if a patient has a head bleed and needs a transfer for neurosurgery, for instance, to call our mothership hospital three hours away and find an accepting neurosurgeon. Then, and only then, approach the patient and tell them the diagnosis: ‘Hey, you have bleeding in your brain; we have to transfer you to Mothershiptown, and Dr. Corporation will be waiting to see you.’ I couldn’t believe my ears. I don’t think that’s right, Dr. Sham.”
I took a deep breath, proceeded to my soapbox, and unleashed a rant upon the universe on corporate bullshit and ethics and autonomy, and over my dead body will that ever happen on my watch. My physician assistant had the insight that my old buddy did not have. Autonomy is the ability to make a personal, uncoerced decision. It is the cornerstone of medical ethics. This demand was the very definition of unethical.
“He says they’ll be watching,” she insisted. “We might be fired if we don’t keep at least 50% of transfers within the system.”
According to this administrator, my friend, we’re supposed to leave patients unaware of their own diagnoses for as long as it takes to be accepted at places within our own healthcare organization for the financial benefit of the company. Places we know damn well no reasonable person would want to go. So instead we document a tome to make sure we don’t get in “trouble”:
“Patient considered our transfer plan and opted to go where they have previously had substantial amounts of subspecialty care…”—and send the patient to the hospital just thirty minutes away. Not a fricking three-hour drive. For the dying woman’s blind seventy-seven year old husband who will probably die trying. Shamelessly forcing us to play this game delays care. To transfer a critical patient two hours instead of thirty minutes? To arrange this tougher type of transport? Good luck EMS. I wondered how long until…
Fast forward a few weeks. A colleague who was grandfathered in, no doubt petrified by the current landscape of surplus, especially given two older docs who were recently “not renewed,” did what he was told to do. Gramma had a fall and brain bleed. Dr. Colleague called the mothership and the slo-mo process of transfer began. Three hours later he is informed that transport is no longer available, they were diverted elsewhere. Two minutes later her nurse told him his patient was not arousable. He placed an endotracheal tube. He tried to arrange transport to the closer hospital, the clear choice hospital. They were full. He found a neurosurgeon at a hospital an hour away. The ambulance was on the way to pick her up.
He signed out to me, “The patient in bed eleven is Mrs. Lee. Her blood pressure is 88/40. She doesn’t look good.” The plan was reviewed: get her the hell out the door, it was her only chance. No one here could save her.
She arrived there three hours after he called them, and was whisked to the operating room, where she died on the table. Then the mothership called. They found an ambulance for our dead patient. I couldn’t wait to tell my colleague. He was distraught over the delay as it was.
Lesson learned. To make sure this never happens to me, any case with a similar risk of mortality or a ticking clock—I document the patient refused my recommendation and make an appropriate transfer without delay. I don’t ask. To me, asking would be more unethical than writing down that I did in order to keep my job and I refuse to be the unethical puppet arm for a corporation’s billfold. Still, I feel paranoid about being fired for doing the right thing to give my patient the best chance.
Is this how it’s supposed to be? It wasn’t my partner's fault; it was the corporation’s fault. It’s greed’s fault. But because we take such extreme ownership of our patients and our practices, it’s easy to forget that and blame each other or ourselves. It is not our fault. We are victims of the bullies, too. Fuck corporations.
- S. Sham
Jul 31, 2021
This blog was created in recognition of the numerous dedicated and fierce young patient advocates who represent the next generation in emergency medicine and other specialties and helped to found Take Medicine Back. Many must remain anonymous for fear of retaliation from oppressive corporations and employers while shouldering an increasing burden of educational debt and an uncertain future sold away from them by the greed of a previous generation.
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