The emergency-medicine physician talks healthcare, staying calm during crises, and Letters from the Pit.
After 37 years of working in emergency medicine (EM) in Austin, Texas, as both a provider and administrator, Dr. Patrick J. Crocker has now written a book on the role of the emergency-medicine physician in the lives of people seeking immediate care. Letters from the Pit: Stories of a Physician's Odyssey in Emergency Medicine addresses the healthcare challenges faced by both physicians and patients.
Do you think healthcare providers and consumers see the system in a similar way?
I suspect both groups can agree on one thing, and that is that the system as it stands is broken. [There are] unnecessary hurdles for both groups running through the healthcare maze, ranging from simple coordination of care, insurance plans, and payment systems that are difficult to understand, let alone work through, [to] cost of care that has become extravagant and general dissatisfaction with healthcare and everything associated with it.
Why is it important that the lay public understand the healthcare system?
First, I believe many patients feel cheated by the system because they don’t understand it. This leads to unrealistic expectations. Without an understanding of how it actually works — which, by the way, is likely impossible given its arcane complexities — [the result will be] distrust and avoidance of care. Our healthcare system has the opportunity to provide “right care, right place, the first time,” but without a basic understanding of the system, this becomes impossible and drives up the cost for all of us. Further, without [patients] understanding or exercising their empowerment, the important element of true preventive care seems sadly elusive.
Is there a temperament necessary to be in healthcare? You are often described as a man with one speed, and that speed is GO! How do you get people to not just do something, but to stand there and observe?
I do think certain temperaments are helpful for physicians. Working within our complicated system of care requires tremendous patience or you will become frustrated, angry, and burned out early. Those that have the interest and ability to walk the line between experiencing empathy for the patient without threatening their own preservation seem to do best. That perspective allows the satisfaction that comes from simply helping another human through their crisis and leads to a better emotional state.
Is adrenaline a good thing, bad thing, or addiction?
Adrenaline has a half-life of 2.5 minutes, so it won’t sustain you.
“Calm is contagious” is one of your mantras. Is the same true of caring or thinking?
All three are contagious. We all learn from the examples of care that are provided in front of us, so leading by open example brings others into the fold of these perspectives. I consider the number of times I have witnessed my exterior calm convert growing panic in the surrounding staff and create a better milieu for care [to be] an achievement. Internally, my initial reaction to a scenario may have been the same as my staff’s, but it’s possible to contain it. Care delivered with thoughtful calm and without panic always translates to better care.
In your book, you talk about the amygdala hijack of healthcare, where the amygdala, which regulates memory, decision-making, and emotional response, predominates. Do you think [a shift] can realistically occur given other drivers of the healthcare system?
I do. We have a frontal lobe for a reason, to override that fast-reacting amygdala that can lead us into so many errors and more fully consider the situation. We all need to learn to exercise that control as a clinical skill. Metacognition, or “thinking about our thinking,” could help prevent many of the recognized cognitive-error traps we can fall into during our care for patients.
In one of your stories in the book, you describe a well-meaning doctor practicing outside of their expertise, resulting in that doctor pulling on brain tissue that the patient probably needed to keep intact. How much of our [healthcare-related] issues are individuals not knowing their limitations, and how much is system overreach or an individual wanting what cannot be provided?
While I do think we are all occasionally tempted to unconsciously stray out of niche, I don’t feel it is a major problem. One thing I see in recent EM graduates is exactly the opposite: over-reliance on phone consultations with specialists and inadequate trust in their own judgment, skill, and experience. Specialists find these consults frustrating, and this further leads to the lack of understanding of our true value to the system of care.
It has been five years since you stepped down as [an emergency department] chief. How has the time and distance from your position changed how you think about healthcare?
I do see it now mainly as a consumer. The average EM physician is usually unappreciative of the obstacles to care that patients encounter, particularly around billing issues, medication costs, and insurance coverage — coverage that seems to say something is covered, but then refuses to pay until multiple requests are made. It seems we should do something about the costs of generic drugs, as well, that sometimes remain out of the reach of many without coverage. Now that I have progressed to Medicare coverage, it seems a bit easier. Perhaps it is time to reconsider healthcare for everyone again at the Medicare level. We are, after all, one of the few developed countries that does not have such a system for everyone.
Tyler Cymet, DO, is the chief of clinical education at the American Association of Colleges of Osteopathic Medicine, and works in the emergency department at the University of Maryland Capital Region.
