That's because you miss out on those most precious first few hours of deep sleep needed for the next day.
For me, the call this particular evening came at 10:47 PM. Seventy-nine years old. Complete heart block. Wide complex escape rhythm at 34. Started to feel poorly early that morning. Stable blood pressure: 134/60.
A decision was needed.
So, I pulled my head off the pillow, glanced at the clock, grabbed by cellphone, and stumbled toward the other bedroom where the home computer rests. Giggling the mouse, the 45,000 watt screen light illuminated, blinding me as I struggled to type in the cellphone-derived time-sensitive passcode needed to log into EPIC alongside my username and password. I entered by username and password again (once is not enough, I guess), then found the particular hospital (I cover four at night when on call), then the Emergency Room patient list, then the room, and there it was: just as advertised, but with the dreaded one-triage note entry in the chart that basically just noted the time the patient arrived. That is the tell-tale sign that no real decision-making is needed for the ER staff. Just "call EP" (aka, me.)
The decision: pacemaker now or pacemaker later?
The mind does strange things with little sleep, but the decision at that time of night was mine and mine alone. No one else was there. No one else in medicine has this much responsibility. No nurse practitioner, medical administrator, or bureaucrat could make this call, but there I was: dead tired with my mind playing tricks on me. I would hear my inner-self rationalizing with the rapid-fire voices dancing in my head:
"Really, now?" ("Yeah, now")So the pacemaker representative and the rest of the team were called as I drove to see the patient (none are happy, but they understood). I placed a temporary pacing wire for backup (thank goodness), implanted the pacemaker, spoke with the grateful family, then drove home for my head to finally meet my lonely pillow at 2 AM. Thankfully without another interruption that morning.
"His blood pressure is stable, and the ER doctor says he looks fine, maybe this can wait until the morning?" (But that nice escape rhythm could quit, the pacer pads might not work, and you'll have to scramble those 10 miles up the road to make it in time.")
"The rep on call lives far away." (Too bad.)
"The staff will be spent, too. They are overstretched and need their sleep." (But this is why we're on call.)
"Maybe just a temp wire, then pacer in the morning daylight hours? (I have to drive there anyway. The temp wire might dislodge, then the patient has NO rhythm... )
"Dude, just do it. It'll save time in the long run and let you sleep without worrying."
After a few hours sleep I woke, knowing I did the right thing. But reflecting back to that brief moment of decision-making the night before, I wondered to myself. Could things have gone differently?
Which brings me to the point of this blog post.
For the past five years, there has been tremendous uproar about the payments and unproven requirements of the Maintenance of (Board) Certification (MOC) mandate for US physicians created out of thin air by the American Board of Internal Medicine (ABIM) and marketed by the American Board of Medical Specialties (ABMS) to fund their bloated salaries, lobbying activities, and for-profit corporate subsidiaries that sell data. Thanks in part to the ACA law that includes the MOC mandate as a "quality" metric included by their lobbying, MOC's payments and needless exercises have became mandatory for employed physicians without their knowledge or consent. And with every passing day, the programs and exercises are promised to be easier, faster, less intrusive, because these bureaucrats continuously claim to know what's best for working physicians on the front-line of 24-hour patient care. They wallow in a sense of schadenfreude as they wield their undeserved power over their working colleagues, purposely naive to the most dangerous side effect their unwarranted and potentially illegal actions risk creating.
Longtime readers know that at least five different antitrust lawsuits have been filed against various non-profit entities that comprise the ABMS member boards in regards to MOC. The largest member board of that consortium is the ABIM, who recently breathed a partial sigh of relief when a Pennsylvania judge dismissed most of the claims of anti-trust tying, monopolization, racketeering, fraud, and unjust enrichment brought by four working internists. While the monopolization, fraud, and racketeering claims remain unresolved at this time, we should note that there might be significant consequences if working physicians don't get their day in court, and it's not what most people expect.
Not having an unbiased judgement in court before a jury of one's peers in these untested legal waters risks the development of US physician apathy.
Too many examples of lying, cheating, and stealing physicians' certification fees for political and economic purposes have occurred since MOC was mandated by the ABMS member boards in 1990. From the quiet movement of nearly $70 million from the ABIM to the secretly created ABIM Foundation from 1990-2007 in the name of "Choosing Wisely," the falsification of tax forms, holding political and corporate appointments while serving as the President and CEO of the ABIM, performing undisclosed lobbying, transferring funds to the Cayman Islands, and using felonious strongmen to invade doctors' houses with Federal Marshals and lawyers, were all accomplished just so their monopoly and partnership with insurers, hospitals, and medical specialty societies could flourish. By quashing the chance for justice against these actions, the courts risk irreparably damaging the integrity of the entire US medical profession and crushing the souls of those who make huge sacrifices on behalf of their patients every day.
This whole ABMS MOC fiasco, especially with the recent opinion to dismiss doctors claims of impropriety against this racket of monied tax-exempt corporations so broadly, risks making doctors apathetic. Could such apathy lead to less-than ideal decision-making in the wee hours of the morning?
For the sake of our profession and our patients, it's time to make sure working physicians get their day in court.