Recently I heard Dr. Sanjay Gupta give a talk at the Marin Speaker Series. He covered a lot of ground (he is CNN's most traveled correspondent), and one of the issues he discussed was altruism. He cited a study linking altruism to neural activation of a pleasure center in the brain. This study substantiated his belief that altruism was a fundamental attribute of human nature, something he has seen consistently and repeatedly on every continent. This observation segued into the role of altruism in the practice of medicine, and this in turn led me to consider the particular role of altruism in the practice of emergency medicine. Although I am not inclined to believe that altruism is a universal human trait, I do think altruistic tendencies play a role in the personal choices we make and the walks of life we tend to follow. Medicine is obviously just one of many professions that offer opportunities to exercise the altruistic muscle; and unfortunately opportunities to satisfy our baser instincts as well. Certainly, emergency physicians (EPs) do not have a corner on the altruism market, but there is no question in my mind that altruism plays a major role in the practice of emergency medicine.
Webster defines altruism as: (1) unselfish regard for or devotion to the welfare of others, and (2) behavior by an animal that is not beneficial to or may be harmful to itself but that benefits others of its species. This is distinguished from devotion to loved ones or friends; it is devotion to the welfare of people you may not know, or ever expect to see again. Altruism is unselfish in that it is not done in the expectation of a return on the investment. In fact, there may be considerable sacrifice involved. Yes, yes, I know that emergency physicians make a pretty good living; and perhaps I and many other EPs would never have considered EM or any other medical specialty if the compensation end of it wasn't reasonably attractive. Considering "Doctors Without Borders" ducking bullets in the Sudan, physicians who volunteer their services for several weeks every year in the poorest towns in Guatemala, or even the docs who practice primary care in under-served and under-insured rural America: how can I possibly justify highlighting emergency physicians in a discussion of medical altruism? Believe me, I have nothing but respect and admiration for the aforementioned volunteers and committed practitioners, and I have no doubt that the general public shares those sentiments. I just wish that, when the practice of emergency medicine came up in general conversation, people would go beyond thinking "Wow, that must be stressful" or "You must see a lot of gunshot victims" to recognize the full implications of "they are the safety net for a beleaguered health care system" and "they care for everyone regardless of health insurance or ability to pay."
Now I readily admit that physicians have lost their altruism luster in the last few years. Emergency medicine is no different. Some ER groups overcharge, and aggressively rely on the out-of-network/balance bill play to pad revenues. EPs do tend to over-test, are in too much of a rush at the bedside, and prescribe when they should be giving reassurance, advice, and encouragement. Emergency care is expensive; and though shifting costs to make up for uncompensated care losses may be a necessary evil, it is still a kind of unauthorized and sometimes regressive form of taxation. Nonetheless, I still believe that the thing that attracts many of the best and brightest new medical school graduates to Emergency Medicine Residency programs is the same altruistic inclination that keeps older EPs coming back to do another Friday night shift in the ER.
Some physicians volunteer, many don't. Some physicians provide a significant amount of charity care, others hardly any. Some physicians are very selective about the patients they are willing to treat, while quite a few open their office or operative schedules to whomever comes their way. However, EVERY emergency physician, no matter where they practice, treats EVERY patient who comes to the ER, and provides care to a substantial number of patients that most physicians prefer to avoid altogether: the dangerously combative sociopath, the disorderly drunk, the abusive addict, the neglected, demented, odoriferous, impacted, foul-mouthed, and incredibly foolish. Emergency physicians as a group provide more charity care than any other specialty, to patients they rarely get to know, and 60 percent of the time they do it on nights, weekends and holidays. EPs are among the first to be exposed to contagious diseases in an epidemic, and will be among the first to treat those who are contaminated with lethal radioactive materials or toxins in a terrorist attack. The stress of managing severe trauma or dealing with parents devastated by sudden infant death syndrome is not the only thing that contributes to burn-out for emergency physicians: it is the taxing, and under-appreciated, day in and day out role of the overwhelmed safety net provider trying to plug the gaps in a failing health care system fraught with unrealistic expectations, threats of malpractice suits, and the constant exposure to barely controlled chaos that makes ER practice so challenging. It wasn't that long ago when EPs were recognized by legislators and policy makers as the "white hat" doctors. Now, EPs are seen as overutilizers of expensive resources, whose efforts to reduce ER wait times and improve patient satisfaction in the ED are derided because these things "encourage Medicaid patients to use the ER inappropriately." Inexplicably to most emergency physicians, and despite significant advancements in the practice, the shine on the apple of emergency medicine is fading.
Fortunately, millions of patients continue to value the ER as an important health care resource; but a society that fails to acknowledge or appreciate altruism is destined to extinguish that behavior over time, regardless of how well the neurotransmitters work.
This post originally appeared on The Fickle Finger on April 3, 2013.