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.
The reality of this MOC debacle is most people do not care about this. 99% of the physician population are content to cough up the money and to become enslaved by the ABIM. Rich Baron is laughing all the way to the bank and the recent ruling will be used in the other 2 open cases. The only Federal court environment that would have been sympathetic to physicians would be a California Federal court. To file a case in Philadelphia was a big gamble that we all lost. It was worth a shot but it clearly failed. Apathy is not a threat. It is reality. Complaining about EMR, physician suicide, physician burnout, MOC, lawsuits, NBPAS, ABMS, Rich Baron, low pay, Physician autonomy (an oxymoron if I ever saw one), CMS is all for naught. It is useless. Physicians don't care. The ABMS doesn't care. HRS does not care. The nation does not care.
The only thing that will be visible to anyone are body bags. Dead patients. Dying patients. Overflowing ERs. The lack of MDs and the use of NPs.
If anybody thinks doing an emergency procedure at 1A matters anyone you are deluding yourself. How do I know?
Wes when you billed the 33208 for that pacer you did emergently, did you get extra pay for coming in heroically to save that patient's life? No. You did not. Your pay is EXACTLY the same as a routine pacer done electively in the afternoon.
That is the valuation my fellow physicians. It is all the same to everyone. It DOES NOT matter.
My plumber gets more money for emergencies. My waiter gets more money for extra work or effort. My lawyer gets to bill proportion to the amount of time and effort spent. My auto mechanic gets paid more for complicated work.
The average physicians gets paid THE SAME because society doesn't care about physicians.
So when what comes around goes around and the EP lab is staffed by physicians who don't care because no one cares, what will happen? When the ER is manned by physicians who don't care anymore because no one gives a crap about them, what will happen? When Rich Baron is old and in need of medical help but meets physicians who don't care anymore, what will happen?
Apathy is already here and has been for years.
It is too late.
I’m very angry. It’s too late at 53 to start a General Contractor apprenticeship. Plumbers are more respected and better paid without the hassles, screaming, derogatory treatment, “provider” bullshit I get all day. Doctors are on the front lines of saving lives and they step and crush us every day, a little more, until we break and thus zombified, do their bidding.
I immediately noted that for the stress, sleep deprivation and driving around Chicago at 2am, you weren’t compensated. You were paid exactly the same as if this had been scheduled at 8am. You suffer the heartburn, the impaired glucose tolerance, the inability to process or think the next few days from sleep deprivation and working a 16 hour day, a few in row. You’re not a spring chick.None after our generation will repeat this. Millennials would ignore the phone and go back to bed. They are never going to take call like this at age 55. Start saying goodbye to the way things were, and start saying hello to the way it will be. Physicians are the most abused and tortured profession, meek and submissive, asking for more, taking all the responsibility, all the blame, for squat. I’m aggressively getting to the point of financial independence to end this hellish career choice, and then maybe make doggy blankets to sell on EBay. It will be a vast improvement on this horse shit.
Will there be an appeal in the 14 day window?
My view, the only solution, to end MOC, is to convince legislators to pass laws as TX; OK, etc. Where MOC is not need it. I do not think ABMS, ABIM will not change from the 'mandatory", status to voluntary. I think too may people/institutions are involved, in this cash frenzy, to make any changes, in ending MOC. Reality !!!.
Many of us that can retire will, to avoid the hazzle of Administrtos, hospitals, insurqnce companies monopoly.
ABMS MOC is toxic for everyone, but it is an even worse poisonous product for those in the uniformed services. If you understand the history of MOC, it started with deception utilizing a propaganda campaign to stir up distrust for physicians beginning just after the time the ABIM Foundation was loading up the truck with millions and millions of physician's surfeit examination fees. (Did anyone mention overcharging!)
The ABMS MOC® products were launched just after the ABIM Foundation was fully loaded in 2007. MOC is based on deception and collusion of the ABMS and member boards. ABIM and the dissemination of disinformation via the newly launched ABIM Foundation played a critical role in undermining the physician and patient in American healthcare. It is fair to say the ABIM has not been serving the public interest or that of the profession.
Why weren't military physicians included and represented in the lawsuit. Everybody wants their day in court. I suggest a broader more comprehensive lawsuit that includes all of us that have been harmed by MOC. Military physicians are only one group that is inadequately served and harmed by the ABMS and ABIM and all the rest of the member boards.
The ABMS with their own words misaligned carefully constructed deceptive words represents themselves and corporate interests not any of us.
Thank you Wes for all your dedication and the PPA's tireless efforts to help us get our voices heard. And especially the physician's who brought the case, brave people who represent the vast majority of us.
Just like the ABIM got it wrong, so did the Pennsylvania judge who seemed to be parroting from the ABIM's own website and giving citations that do not equate. We are talking about lives that matter. Physician and patient lives. This unique case has no precedent.
It is unfortunate that the fight was thrown before we had a chance to fight for physician and patient rights. All people's rights. Everyone loses if the truth is dismissed before facts have a chance to be feathered out and heard. The dismissals of meaningful and profoundly real complaints such as were presented to the court is an egregious tragedy, unless it is remedied.
A winner who makes no appearance to the fight, especially when he or she is not popular or trusted, always runs the risk of backlash, taking on the appearance of coward and fool.
Always a bad marketing tool to use a fool or coward for your front cover.
I don't think anyone harbored the illusion that a fight to end MOC would be easy. But it's an intelligent David possessing a clever sling and stone of truth that will win in the end.
David always wins in the cycles of time and recurrence.
I believe those who hold the umbrella of facts will always win as well, if given a fair chance, over the dark umbrella using shadow play. Unless the shadow play has a chance to be exposed deceivers (and their horrible marketing campaign) for a while prevails. But only for a short while, if you ask me.
Do you really know what the ABMS and ABIM are up to? They should be paying you!
it not apathy its fear from years of intimidation
I am a psychiatrist and would like to share some thoughts. It is very frustrating to practice medicine in today's society due to a variety of factors. It can seem hopeless when the leaders of our organizations should be trying to help improve our lives but are instead acting in selfish and corrupt ways that only contribute to physicians' misery. It becomes easy to perceive that we will continue to endlessly suffer and they will endlessly triumph. These leaders, like many people around us, are under the illusion that intentional negative behaviors will have no consequences for them. But this is a false illusion. If a person intentionally causes harm to others, they will have to eventually experience negative consequences. People commonly believe that they will escape these consequences but they cannot. I frequently witness people in my personal life and at work (patients) who suffer from the consequences of their selfish and negative intentional behavior.
Of course, we are frustrated and want our perpetrators to suffer right away. but sometimes that does not happen. I have a relative who is a geriatric psychologist and works in nursing homes and rehab centers. Every day at work, she witnesses elderly, sick and lonely people grappling with the end results of their selfish, abusive, or corrupt life choices. Look around you. You know people who behave in selfish, abusive or corrupt ways. How do their lives evolve? Watch the news and read news reports. It is filled with these people.
Of course, bad things also happen to good people but this is not the phenomenon I am writing about. It is easy to forget that we also reap positive results from the good things we do for others because we are tired, frustrated, overworked and under appreciated. It is hard to fight a simultaneous battle against both sickness and evil.
Let us now read a list of people who behaved in selfish, corrupt and abusive ways (sometimes for decades) under the illusion that they would never have to suffer the consequences of their behaviors (in no particular order): Harvey Weinstein, Bill Cosby, Billy McFarland, Jeffery Epstein, Ghislaine Maxwell, Prince Andrew, Bernie Madoff, Ruth Madoff, David Miscavige, Elizabeth Holmes, Louis CK, Keith Raniere, Allison Mack, Claire Branoff, Kevin Spacey, Les Moonves, Matt Lauer, Larry Nasser (sadly one of our own), Warren Jeffs, Paul Manafort, Martin Skreli, David Sackler, Joss Sackler, R. Kelly, Lori Laughlin, Felicity Huffman, Rick Singer, all the participants in the college admission scandal, thousands of Catholic priests, and a very long list of politicians. I am sure you can think of more.
I know that many physicians are frustrated with their current work environment. If you are unhappy with your current job, I encourage you to make every effort to find a new one. You have worked too hard to settle for a bad job. Look into different options. Try to work at a place where you feel valued and appreciated. Things may be more negotiable than you think. Also, if possible, transfer your board certification from an ABMS group to the NBPAS. An attorney recently told me that the best way to break up a monopoly is for people to join the smaller organization so it becomes more powerful.
And finally, I request that you please refrain from making any negative comments about my post. if you do not agree with something I have written, please reread it and think about it for awhile. Take care and don't give up hope.
"It is hard to fight a simultaneous battle against both sickness and evil."
So true, and the fact that you said this and more, sharing in an intelligent insightful discussion, provides objectivity and restorative hope.
Your attorney friend is correct, there is strength in numbers.
I think most people do care and this is a winnable fight, but it will take time, money and persistence. Lawsuits are only one avenue; the court filings show how serious we are.
Hello there. This is the same above psychiatrist with one more comment. In the medical field, we are accustomed to things often moving at a fairly rapid pace. We can administer treatments and see results in a relatively short period of time. This is not the case in the legal field or government where events evolve at a much slower (often excruciatingly slower) pace. Although it is frustrating, we need to be very patient and persistent to achieve our goals. Hang in there! (P.S. Take a minute to go to my above post and read again my list of shame. Now take a few minutes to ponder the amount of misery these selfish individuals inflicted upon their families and victims. Mind boggling, isn't it?)
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