“my patient”: striving for a distinctive medical ethic

EDITORIALS

fact that 101 eligible pat ients were not enrol led during the s tudy period does not suggest increased phys ic ian efforts in obtaining a history.

In add i t i on to a s e rum a c e t a m i n o p h e n concen t ra t ion , i n t e rp re t a t i on of the R u m a c k - M a t t h e w s n o m o g r a m for ace taminophen toxic i ty requires that the t ime of inges- t ion be known. An error of one to two hours in es t imat ing the t ime of ingest ion can s ignif icant ly al ter in te rpre ta t ion of the potent ia l for toxicity. 4 If the h is tory of drug inges- t ion in the overdose pa t ien t is unrel iable, why can cre- dence be given to the h is tory of the t ime of ingestion?

If the c l in ic ian de te rmines that serum ace taminophen screening is to be under taken, screening issues should be discussed wi th the toxicology laboratory and proper con- f i rmat ion procedures established. A t t e m p t s at conf i rming the h i s to ry are indica ted , and the m e t h o d of co l lec t ing data regarding the inges t ion should be evaluated. A single, unconfirmed, unexpec ted test resul t should not be consid- ered proof of drug-induced tox ic i ty when there is no his- tory of ingestion, just as a negat ive test resul t does not

prove the absence of a drug.

Wil l iam A Watson, PharmD Schools of Pharmacy and Medicine Depar tmen t of Emergency Health Services Universi ty of Missouri, Kansas Ci ty

1. Kelly KL: The accuracy and reliability of tests for drugs of abuse in urine samples. Pharmacol Ther 1988;8:263-275. 2. Ingelfinger JA, Isaakson G, Shine D, et ah Reliability of the toxic screen in drug overdose. Clin Pharmacol Ther 1981;29:570-575. 3. Hansen HJ, Caudill SP, Boone J: Crisis in drag testing - Results of CDC blind study. JAMA 1985;253:2382-2387.

4. Smilkstein MJ, Knapp GI, Kulig KW, et ah Efficacy of oral N-acetylcys- teine in the treatment of acetaminophen overdose - Analysis of the Na- tional Multicenter Study (1976 to 1985). N Engl J Med 1988;319:1557-1562. 5. Ray JE, Reilly DK, Day RO: Drugs involved in self-poisoning: Verifica- tion by toxicological analysis. Med J Aust 1986;144:455-457. 6. Qirbi AA, Poznaksi WJ: Emergency toxicology in a general hospital. CMAJ 1977;116:884-888. 7. Garriott JC: Interpretive toxicology. Clin Lab Med 1983;3:367-384.

"My Patient": Striving for a Distinctive Medical Ethic

It was suggested recent ly that the t ime is ripe for the medica l profession to adopt i ts own set of e thical values. 1 These values would be dis t inct from those values incum- bent upon c i t i zens as a m a t t e r of c i t i zensh ip ; separa te from those values designated through the various opera- t ions of the legal system; and discrete from those personal values derived from an individual ' s culture, religion, and upbringing. The d is t inc t ive medica l e thic should not be based, i t is suggested, on a renewing of the condescension coupled wi th au thor i ty our forbears often used. Rather, i t should be based on the physic ian 's role-specific dut ies and responsibi l i t ies as a professional. The purpose is to avoid having all of a physic ian ' s professional act ions and mora l c o n v i c t i o n s s a n c t i o n e d by one of t he t h r e e e x t e r n a l sources of e thical values. This, though, seems to be a diffi- cul t concept . If a d i s t inc t ive med ica l e th ic is d ivorced from m a n y basic e thical bulwarks, where do we begin?

Perhaps, as emergency phys ic ians , we can s tar t at a place that many others in our profession take for granted (albeit not always fol lowing thei r words wi th congruent deeds) by personal iz ing our pat ients . Other special is ts in pr imary care fields often develop a personal, ongoing rela- t ionship wi th their pat ients . The c l in ic ian is able, based on a knowledge of the pa t ien t ' s personal life, values, and beliefs, to develop a special relat ionship. It is a relat ion- ship that both recognizes their pa t ien ts as individuals and acknowledges the vulnerable posi t ion they are in as pa- t i en t s . T h e s e c l i n i c i ans ove r t l y s t a t e th i s p o s i t i o n to others when they speak of " m y pat ien ts . "

In m y emergency medic ine practice, however, no mat- ter how much lip service is given to not speaking of " the

gal lbladder in room 9," " the MI on the ] idocaine drip," or " the t r auma code from Inters ta te 10," i t is under only the mos t unusua l c i rcumstances that I wi l l speak of an indi- vidual as " m y pa t ien t . " Collect ively, of course, they are m y pat ients . I am responsible for t hem paternal is t ical ly, legally, and in the broad moral sense tha t I am their physi- cian. When I divide the work load wi th other physicians, the pa t ien t m a y also be " m y pa t ien t" in the mos t l y pe- jorat ive sense of being m y burden. Nowhere , though, am I speaking , or m o r e i m p o r t a n t l y t h ink ing , of t h e m as individuals .

Yet are they really, as individuals, m y patients? Other physic ians will , in mos t cases, t reat thei r rout ine ills, fol- low up on their care, or admi t t hem to the hospital . I am but a way s ta t ion on their travels through the medica l sys- t em - the s teward guiding t hem to the right door for pas- sage on their medica l journey. But I am not " thei r doctor"

- as they are often quick to poin t out. This, however, should not discourage ei ther me or my

colleagues in emergency medicine. We know that because of our unique body of knowledge and ski l ls we are, in fact, thei r doctor at the present t ime, and this is the t ime that counts. Rather than dwell on the patient 's re la t ionship to us, we should concentra te on our re la t ionship wi th the pa t ien t - and how i t affects us as physicians. Viewing the individual who is receiving t r ea tment in the emergency depar tmen t as " m y pa t ien t" goes a long way toward com- p le te ly al ter ing our v is ion of our mora l role as emergency phys ic ians . N o longer is the pa t i en t a pure u t i l i t a r i an m e a n s to an end (a p a y c h e c k , t h e good l ife , ge t t i ng through wi th a shift). Rather, the pa t ien t now represents

162/1127 Annals of Emergency Medicine 18:10 October I989

an end in himself. The end is now, in conformance with basic Hippocratic

principles, patient- rather than physician-centered. And, while the outcome may be the same in terms of the pa- tient's physical well-being, the physician has grown pro- fessionally.

Kenneth V Iserson, MD, FACEP Section of Emergency Medicine University of Arizona College of Medicine Tucson

1. Churchill LR: Reviving a distinctive medical ethic. Hastings Center Re- port 1989;19:3:28-34.

Field Times Time. As physicians, particularly in emergency medicine, we

are obsessed with the use, or misuse, of time all around us. The only accurate clocks are our own. If not on our time then not on time, not timely. And the faster, the more timely, the better? Where did the idea that faster is better come from? Have you eaten any "fast food" lately?

Fast medicine. Is it better or only faster? Fast track, quick track, urgent track, urgent care, speedy care, rapid care. . . Wait a second! Where did the idea come from that "fast" and "care" go together?

See related article, p 1119

As emergency physicians, we believe that there are some circumstances that necessitate very rapid appropri- ate intervention, in order to improve chances of a worth- while outcome. Eisenberg's landmark work on cardiac ar- rest down time and survival helped to define some of these circumstances where time truly is of the essence. However, the majority of circumstances may not justify faster, for surely patient care and caring is the first to suf- fer.

Our physician surrogates and colleagues, EMTs who practice emergency medicine in the field, take their cues from us with regard to what is important. It is our guid- ance and knowledge that establish and direct their priori- ties. We cannot fault them for not knowing what we have not taught them. Neither can we blame them when we have not guided them. We have taught our paramedics how to manage cardiac arrest in the field, but have we taught them how to care for the people that they come in contact with? Typically we have not. Have we helped them to truly understand medical care? Again, I feel we have not. And why not? We ourselves have become so en- veloped in the health care industry, surrounded by ever- increasing technological advances, medicolegal con- straints, and health economics that the art of medicine, the art of caring for patients, is being devoured by the business of patient care.

The article by Pointer and Osur in this issue of Annals is a prime example of emergency medicine's failure to pri- oritize for prehospital personnel that which is important. Economic and physic ian t ime constra ints mandated

changes in their medical control system, yet at what point did patient care issues enter the picture? If in fact the sys- tem was trying to improve patient care and the quality of that care, then the changes would be laudable. Yet the only measure evaluated was that of decreasing time spent in the field. For critically ill and unstable patients this would appear beneficial, unless appropriate interventions were now delayed until hospital arrival.

The silver l ining in this cloud may be that un- knowingly, this system demonstrated that which we all would like to believe. The rigorous and detailed increase in quality assurance that accompanied the medical con- trol changes is more likely at the heart of the differences seen. With less direct on-line communication and control, there must be an increased off-line evaluation of care pro- vided. And, although the authors would like us to believe that no one in the field had any idea that the study was occurring, or was to occur, they must also have us believe that with the increased quality assurance that no one was informed of the time it took to accomplish the care in the field. If standing orders alone are responsible for the short- ening of field times, then why did the re-establishment of some on-line communicat ions further improve these "t ime savings"? The answer again lies in the increased quality assurance activities, increased physician and nurse off-line involvement, and education of the field personnel to new priorities.

Dr Ronald Stewart's closing paragraph in his chapter in ACEP's new EMS text states:

On-line medical direction of an EMS system is the hub of that system. While the configurations may vary, the basic tenets do not: The care delivered by prehospital care teams is the practice of medicine in the streets, credentialed physicians must oversee such care, and patients have the right to expect the EMS system to provide the finest of care, promptly, caringly, and mindful of the trust of those served. 1

Quality patient care must be the keystone on which all prehospitaI medicare care issues are decided.

Joseph A Salomone, III, MD, FACEP Asheville, North Carolina

1. Stewart RD: On-line medical control, in Roush WR {ed): Principles of EMS Systems, ed 1. Dallas, American College of Emergency Physicians, 1989, p 101-108.

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