The ED can be a challenging place to work. Patients are anxious, injured, in pain, and may have unrealistic expectations of the services we provide. A smaller number of patients are also drunk, high, or acutely psychotic. Captains of industry feel suddenly powerless to control their circumstances. Said captains are unaccustomed to the symphony that arises when one is situated between a crying toddler and a scromiting (screaming + vomiting) substance abuser.
We can reassure our patients that we will provide the same care we'd want for our families, but what they most desire - certainty and reassurance that everything is and will continue to be okay - is often beyond what we can reasonably offer.
That mismatch between expectation and reality is one factor in what is commonly known as the f-you to thank you ratio, a characteristic that captures the essence of a given Emergency Department in a single, telling metric. It refers to the proportion of patients who, after you have rendered care and completed their evaluation, are likely to reward your efforts with either a hearty f-you or a heartfelt thank you.
When I was looking at residency programs, my two top ranked programs varied considerably on this metric. One was an inner city county hospital, tipping towards the f-you scale. The other was a combined tertiary university hospital (thank you) combined with a suburban location county hospital caring for a very appreciative population that tended toward blue-collar and immigrant workers (thank you SO much). I ended up at the latter program, and that twist of fate made for a much more pleasant training experience.
In my current job, which rates firmly on the thank you end of the continuum, we still get our share of challenging, f-you patient encounters. These cases, like the mystery of the vanishing heart attacks and strokes, seem to have receded significantly since the onset of the COVID pandemic.
Strange inversions of the world as I know it have been occurring on a regular basis over the past couple of months.
Some of our prickliest consultants, usually loathe to hear from an emergency physician and quick to express that feeling in less than diplomatic words (if I'm calling you, it usually means you need to do work) are cautioning me to be careful, and thanking me for being on the front line.
Although I am accustomed to bringing my own meals, there have been several weeks where local restaurateurs sent bins of decadent food for the ED staff to thank us for caring for the community. As one colleague who tends toward cynicism put it, "Weird. This is beyond the time period where I'd expect they just need to get rid of produce before it expires."
A local PCP, known to me previously only from phone calls about patients he was sending to the ED or those I'd seen who needed close follow up, dropped off two acrylic intubation boxes for our ED that he'd manufactured in his garage workshop after hearing that such devices might help protect staff from contagion during the aerosol generating procedure. "You guys are in the hot zone, and I'm happy to support you any way I can."
The neighbors we usually rely on to pick up mail when we are away (and for whom we do the same) called to drop off N-95 masks leftover from a long-forgotten drywall repair job. Cousins from New York who make a living importing and exporting cell phone accessories from China asked if we needed them to order us additional PPE.
An internist from the east coast, a dear friend of my wife's, immediately dropped a dozen masks in the mail when we were still worried about potential PPE shortages early in the pandemic. My mom has called twice to alert me that friends of friends have hand-sewn masks and dropped them off so that I will have some form of protection at work. Relatives in Canada sent me a video of their toddlers banging pots and pans as part of the nightly 7PM cacophony intended to support first responders, along with the caption, "They are clapping for you."
Everyone suddenly saying thank you like this is unexpected, heartwarming and weird.
I'm grateful to have that much more thank you than f-you in my professional life, even if I don't expect it to last.
Years from now, I'll recall the time when the rest of the world noticed how fragile our safety net can be and how close it came to snapping, and stopped to thank a few of us who make it our business to hold the frayed ends together.
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What a great uplifting piece of work to read during the time where things feel a bit frightening.
It is great that the Frontline workers are receiving accolades and tokens of appreciation for what in the past could feel like a thankless job. It is definitely one of the bright spots coming out of this pandemic.
Author
It won’t last, but I’ll savor the memory all the same.
I have been doing phone and video visits where I barely help anyone.
Yet ALL of the patients have been so polite and thankful. They express gratitude and admiration for what I do. It has been validating and motivating.
Pretty soon I expect the more normal ratio to return, but for now, I’m basking in the goodness.
Author
WD,
I’m at your side making hay while the sun shines. It’ll rain on our parade soon enough, I’m sure…
We’ll jointly expect little of humanity and be pleasantly surprised when our expectations are surpassed.
Thanks for doing what you do, my friend,
CD
I have had the exact same experience. Continues to feel quite weird.
I will be sad when the usual lunacy returns but happy to not be in in the bizzaro world anymore.
From one ER doc to another, where have you been all my life Crispy Doc?!? Why am I just NOW finding you? You’re speaking my “language” and I want to read more of what you speak!
Author
Dear Another ER Doc,
You just made my week. And for the record, I’ve been right here all along, in the corner holding the dictaphone, wearing a helmet I ordered online that sort of resembles a welder’s mask as part of my do-it-yourself Mad Max PPE look, with shoes whose stains it’s best not to ask about. That’s right – dressed just like you.
You have a standing invitation to my party – in fact, we’ve been expecting you for some time.
I love it when kindred spirits meet!
CD
From a fellow JAFERD, I’d like to add the noticable lack of administrators walking around is a bonus. Times like this reveal of how little use they are.
Author
Greg,
Point well-taken. I sometimes daydream of asking policy-makers to patrol our ER corridors lined with sick people, wearing the surgical masks they’ve provided us, as a litmus test to show they’d abide by the standards they set for their pit docs.
Your comment caused me to look up JAFERD – first I hear of it, but what a wonderfully apt acronym. Maybe I’ll append it to my card following FACEP and FAAEM, as an inside joke.
Appreciate your stopping by,
CD
Well there are a number of docs out there who are firmly in the f-you side. The f-you coming from the system (hospitals, contract groups). I realize that the volumes are down and that decreases the need for “providers” (doctors) but maybe the “heroes” need a little better treatment.
Author
Scott,
When Oddyseus returned home to Ithaca, contrary to receiving a hero’s welcome, Athena disguised him as a beggar where he endured abuse and insults. I’m convinced he was the first ER doc.
I definitely worry about careers with contract groups, where physicians have progressively less say in how their business is run. No free meal or atta boy will replace the sense of controlling our destiny.
Regarding hospitals, in EM we serve at the pleasure of the C suite, so the best thing we can do is participate fully so those in the C suite know and rely on our stewardship and counsel. It’s no guarantee, but every little bit that we can become known and trusted quantities to those in power helps.
It can certainly feel like a backhanded compliment to get pots and pans banged for you the evening before your contract group cuts your hours or lets you go completely. Here’s to hoping that as volumes recover, our colleagues regain their job security and stability.
I’m packing a parachute beneath my cape to pad my untimely return to earth – just in case my “hero” status vanishes with fickle public opinion.
Thanks for what you do, Scott.
CD
Great comments
Add in that we should have the same option to demand C-Suite folks note that they can be
Replaced on the spot, too.
Author
Robert,
And here I thought I was an optimist! You take dreaming big to a whole new level, my friend.
Appreciate the sentiment,
CD
Your great piece helped a lot of frontline docs break into a smile. Thanks on their behalf.
Author
Rick,
I’ve been listening to you on the Rick and Jerry show since I was a tadpole learning to do my first I&D, so this is about as good as praise gets.
Thanks for sending a ray of light to guy who normally works where the sun don’t shine!
Fondly,
CD