Is it worth it?

As I drive home the 75 miles from the small Indian Health Service hospital where I volunteer as an emergency physician, I find myself wondering, "Why am I doing this? Is it worth it?" It's been a difficult morning. And it's been a difficult few days in my salaried practice, as well—all the result of too few resources to deal with too much need in a healthcare system that often works against my patients rather than for them.

In a rare quiet moment at work two days ago, I was talking to a fellow physician who had been forced to give up his solo pediatric practice because he couldn't meet the increasing costs of his malpractice insurance and his employees' health insurance. He told me that his HMO reimbursement for childhood immunizations no longer even covered his cost of giving the vaccines. This in a system in which increasing numbers of healthcare dollars are being siphoned off to pay for overwhelming administrative overhead and astronomical salaries for insurance company chief executives.

The perverse irony of it all continues to rankle as I ponder the events of my day. The ED was empty when I arrived at 7 a.m., but it didn't stay that way for long. A 4-month-old baby, an apparent victim of SIDS, was already on his way in by ambulance. Although the attempt at field resuscitation had been stopped and the child had been pronounced dead, we would soon have the task of caring for the family and the other inevitable victims of SIDS.

The paramedics who brought the child in looked tired and gaunt. It was a difficult end to their 24-hour shift. One told me that all he could think about was going home and holding his own baby. But in this small, rural ED, the one on-duty nurse and I had little time to spend with either the family or the paramedics, as we soon received two more ambulance calls; one was bringing in a man who was bleeding and the other a man with chest pain.

At the scene of the first call, the EMTs had found a young man with a large scalp laceration lying in a pool of blood—a victim of the all-too-frequent interpersonal violence that we see here. He was hypotensive, tachycardic, and responded only to pain. The EMTs called for helicopter evacuation while they transported him to our ED for continuing resuscitation.

After arrival, he began to respond to fluid administration, but I had to spend more time meeting EMTALA transfer requirements and filling out required paperwork than I had spent in his evaluation and treatment. Had he been picked up at the scene by the helicopter, he would have been taken immediately to the nearest hospital capable of providing him definitive care. But because he came to us pending arrival of the helicopter, he now couldn't budge until all the required boxes were checked and the EMTALA forms were filled in. The paperwork had become more important than the patient.

We were lucky that our man with chest pain was stable, because the time I had spent meeting EMTALA requirements was time I didn't have for him or the other patients who were now rapidly filling our small emergency department: a man with an itchy rash; a woman with end-stage renal disease on dialysis who now had fever, nausea, and weakness; a young mother with a congested 2-month-old baby; an intoxicated man who had been struck in the head and face with a baseball bat; a high-school student with a hand laceration; an old gentleman who had fallen out of bed and had nasal deformity and bleeding; a suicidal young woman who'd sprayed insecticide in her mouth; a multiparous woman in labor; a middle-aged woman (the mother of the man we had just transferred out by helicopter) who was weak and dizzy.

Having temporarily completed my compulsory clerical duties, I began making my way to the other patients. As I did, a medical student introduced himself and told me he would be accompanying me in the ED. I enjoy teaching and welcome the opportunity to share what I know and don't know with students and residents, but I realized there would be precious little time for teaching that morning.

So we progressed as best we could, treating the patients for whom we had the capability, and attempting to transfer to other hospitals the ones who were beyond our level of care.

I spoke with consultants and accepting physicians, and filled out more EMTALA paperwork. On one occasion I found myself arguing with an overworked hospitalist to try to get my patient with fever and renal failure admitted to an in-town hospital for what I feared was sepsis. I'm sure neither the hospitalist nor I fully appreciated the stressors the other was dealing with at the time. When I finally turned my remaining patients over to the physician who relieved me that afternoon, we were still waiting for the hospital to call us back with a bed.

Bed shortages at all the in-town hospitals have become a recurring problem, and sometimes we end up transferring our patients over 100 miles farther away just to find an available bed. These shortages have resulted in ED overcrowding, long waits for patients, problems for the EMS providers, and increased stress for patients, nurses, and physicians like the hospitalist and myself.

These thoughts continue to run through my mind on my drive home. Why do I put up with the stress? Why do I deal with a system that constantly works against me and my patients? Why do I subject myself to the ever-present threat of a malpractice suit? One reason I make this 150-mile round trip is that there is no place to volunteer in town that can provide my malpractice coverage. And my insurance at work won't cover my volunteer activities. So if I want to volunteer in my own community, I have to provide my own malpractice insurance.

I suppose I could just stop practicing altogether. As a retired military physician, I really don't need the additional income from my salaried job. But as I think about my day, I realize that, despite the dysfunctional system, we did make a difference for at least some of our patients.

We relieved a new mother's anxiety and helped her care for her baby. We gave the woman with fever and weakness needed antibiotics, and we treated her nausea and made her more comfortable while we arranged for a hospital bed. We repaired the high-school student's hand laceration and instructed him and his mother how best to care for it. We resuscitated the young man in hypovolemic shock and transferred him to a hospital that could provide definitive evaluation and treatment. He will get another chance at life. I hope he makes the best of it.

I also hope that the medical student who was with me today was able to learn something, despite my limited instruction. And as I think about it, most of the patients I see in my salaried practice appreciate what we do, even if we're sometimes rushed and can't spend as much time with them as we'd like.

So I, like most physicians, am lucky to be able to do what I do. Few in this world have a similar opportunity to make such a difference in the lives of others. It's sad that I should even have to ask myself, "Is it worth it?" I decide the answer is Yes. But I realize that for an increasing number of my fellow physicians, the answer is No. And sometime in the future, without badly needed change in our healthcare and legal systems, my answer may be the same.