Speaking Your Mind

Breaking the Code of Silence:Breaking the Code of Silence:questioning authority and questioning authority and authoritiesauthorities

Edwin Leap, MD, FACEPEdwin Leap, MD, FACEP

24 May, 200724 May, 2007

Grand RoundsGrand Rounds

Department of Emergency MedicineDepartment of Emergency Medicine

West Virginia University HospitalWest Virginia University Hospital

Breaking the Code of Breaking the Code of SilenceSilence Why should you care what I Why should you care what I

think?think?

I’m not an academic, not an I’m not an academic, not an administrator, not a researcher.administrator, not a researcher.

Breaking the Code of Breaking the Code of SilenceSilence You should care what I think You should care what I think

because I care what you think.because I care what you think.

And opinions matter, mine and And opinions matter, mine and yours.yours.

Just ask a pollster; or a political Just ask a pollster; or a political candidate.candidate.

Breaking the Code of Breaking the Code of SilenceSilence But, you still may not; so grab a But, you still may not; so grab a

quick nap. There isn’t a quiz.quick nap. There isn’t a quiz.

Breaking the Code of Breaking the Code of SilenceSilence I’m an emergency physician, I’m an emergency physician,

which means:which means:

Alcohologist, dispositionist, Alcohologist, dispositionist, deceptionist, regulatologist, deceptionist, regulatologist, altercationist, paresthesiologist, altercationist, paresthesiologist, analgesiologist, etc.analgesiologist, etc.

Breaking the Code of Breaking the Code of SilenceSilence My pedigree:My pedigree:

Marshall University, BS ZoologyMarshall University, BS Zoology

WVU, MDWVU, MD

Methodist Hospital of Indiana, Methodist Hospital of Indiana, ResidencyResidency

Breaking the Code of Breaking the Code of SilenceSilence Community Hospital PracticeCommunity Hospital Practice

37,000 visits per year, nine partners, 37,000 visits per year, nine partners, three PA’s.three PA’s.

One wife, four children.One wife, four children.

Unknown number of dogs.Unknown number of dogs.

Breaking the Code of Breaking the Code of SilenceSilence I’m also a writer. Thanks in no I’m also a writer. Thanks in no

small part to:small part to:

Mrs. McCarty’s English class, Mrs. McCarty’s English class, Barboursville High School, 1979-Barboursville High School, 1979-1982.1982.

Breaking the Code of Breaking the Code of SilenceSilence But I didn’t write much until I was But I didn’t write much until I was

in practice, and my children were in practice, and my children were born.born.

Breaking the Code of Breaking the Code of SilenceSilence That is, until I began to really feel That is, until I began to really feel

passionately about making the passionately about making the world better…for them.world better…for them.

Breaking the Code of Breaking the Code of SilenceSilence In 1997, I began writing for the In 1997, I began writing for the

Greenville News, Greenville, SC. Greenville News, Greenville, SC. ‘Chest Pain,’ was my first article.‘Chest Pain,’ was my first article.

I don’t write about cholesterol or I don’t write about cholesterol or foot fungus.foot fungus.

Breaking the Code of Breaking the Code of SilenceSilence I write about family, faith and I write about family, faith and

medicine, and how old people can be medicine, and how old people can be so mean.so mean.

I write about fathers abandoning their I write about fathers abandoning their wives and children, about mean wives and children, about mean drunks, the Confederate Flag, drunks, the Confederate Flag, prescription drug abusers and lots of prescription drug abusers and lots of other things.other things.

Breaking the Code of Breaking the Code of SilenceSilence In 2000, I began writing for In 2000, I began writing for

Emergency Medicine News. Emergency Medicine News.

Monthly column, up to 2000 Monthly column, up to 2000 words.words.

Extreme editorial freedom. Very Extreme editorial freedom. Very rare.rare.

Breaking the Code of Breaking the Code of SilenceSilence What have I written about over the What have I written about over the

years?years? What makes our job hard; what we What makes our job hard; what we

endure at night; death; natural endure at night; death; natural selection; abuse of our time; loss of selection; abuse of our time; loss of our hope; loss of our passion; loss of our hope; loss of our passion; loss of our freedom; loving patients; disliking our freedom; loving patients; disliking patients; loving doctors and medicine; patients; loving doctors and medicine; disliking both.disliking both.

Breaking the Code of Breaking the Code of SilenceSilence I’ve also written about: Pay for I’ve also written about: Pay for

Performance; the LLSA; the pain Performance; the LLSA; the pain scale; patient satisfaction scores; scale; patient satisfaction scores; crazy people; sad people; violent crazy people; sad people; violent people; drug abusing people; people; drug abusing people; unprofessional doctors; home-unprofessional doctors; home-schooling; parenting…schooling; parenting…

The list keeps growing.The list keeps growing.

Breaking the Code of Breaking the Code of SilenceSilence I may not be doing formal I may not be doing formal

research, or cutting up rats to research, or cutting up rats to examine hepatic mitochondria.examine hepatic mitochondria.

But I’ve learned a lot about But I’ve learned a lot about emergency medicine.emergency medicine.

Breaking the Code of Breaking the Code of SilenceSilence People send me their stories and People send me their stories and

tell me their frustrations. tell me their frustrations.

I get a look inside the lives of my I get a look inside the lives of my colleagues, and inside the colleagues, and inside the dynamics of our field.dynamics of our field.

Breaking the Code of Breaking the Code of SilenceSilence And to this day, I get notes that And to this day, I get notes that

say:say:

‘‘Thanks for saying that.’Thanks for saying that.’

Breaking the Code of Breaking the Code of SilenceSilence

‘‘You said what I was feeling, but You said what I was feeling, but didn’t know how to say.’didn’t know how to say.’


‘‘I’d say it, but I have no place to I’d say it, but I have no place to do so.’do so.’


‘‘I thought I was the only one…’I thought I was the only one…’

Breaking the Code of Breaking the Code of SilenceSilence I’m always touched by ‘I thought I I’m always touched by ‘I thought I

was the only one.’ was the only one.’

One of the most terrifying feelings One of the most terrifying feelings is the sense of isolation.is the sense of isolation.

If you feel or think something, If you feel or think something, chances are you aren’t alone.chances are you aren’t alone.

Breaking the Code of Breaking the Code of SilenceSilence Even if what you feel or think is, Even if what you feel or think is,

well, odd.well, odd.

Breaking the Code of Breaking the Code of SilenceSilence I occasionally get notes that say I’m:I occasionally get notes that say I’m:

Unprofessional, burnt-out, insensitive, Unprofessional, burnt-out, insensitive, unkind, judgmental, hyper-religious, unkind, judgmental, hyper-religious, environmentally uncaring, etc.environmentally uncaring, etc.

A writer who offends no one isn’t A writer who offends no one isn’t much of a writer.much of a writer.

Breaking the Code of Breaking the Code of SilenceSilence Just ask this guy: Salmon Just ask this guy: Salmon

Rushdie, author of ‘The Satanic Rushdie, author of ‘The Satanic Verses.’Verses.’

Breaking the Code of Breaking the Code of SilenceSilence I often receive letters through I often receive letters through

EMN that say:EMN that say:

‘‘I like what you said! It was so I like what you said! It was so true!’ true!’

‘‘But please don’t print this letter.’But please don’t print this letter.’

Breaking the Code of Breaking the Code of SilenceSilence Far worse, I get comments like Far worse, I get comments like

these:these:

‘‘I’d say what you did, but I’m I’d say what you did, but I’m afraid.’afraid.’

‘‘I’d love to say that, but I’ll get I’d love to say that, but I’ll get fired.’fired.’

Breaking the Code of Breaking the Code of SilenceSilence Let me repeat that:Let me repeat that:

‘‘I’ll get fired!’I’ll get fired!’


And this from prominent And this from prominent physicians!physicians!


I chose to talk about questioning I chose to talk about questioning authority, in large and small authority, in large and small ways, because many physicians ways, because many physicians are afraid to do just that.are afraid to do just that.

Breaking the Code of Breaking the Code of SilenceSilence In America today, doctors fear firing, In America today, doctors fear firing,

or censure, loss of tenure or loss of or censure, loss of tenure or loss of income, if they speak their minds.income, if they speak their minds.

I don’t mean speaking their minds I don’t mean speaking their minds like Imus.like Imus.

Just the truth, as these doctors see it.Just the truth, as these doctors see it.

Breaking the Code of Breaking the Code of SilenceSilence See, crazy me, I always thought See, crazy me, I always thought

that these people…that these people…

Breaking the Code of Breaking the Code of SilenceSilence And this document…And this document…

Breaking the Code of Breaking the Code of SilenceSilence Meant to preserve the free Meant to preserve the free

speech of everyone.speech of everyone.

Factory workers, housewives, Factory workers, housewives, politicians, children, immigrants politicians, children, immigrants and educators…and educators…

Even doctors.Even doctors.

Breaking the Code of Breaking the Code of SilenceSilence So, how did medicine get here?So, how did medicine get here?

We used to be independent We used to be independent thinkers.thinkers.

We used to believe our opinions We used to believe our opinions mattered.mattered.

Breaking the Code of Breaking the Code of SilenceSilence What did doctors do before they What did doctors do before they

became so afraid to speak?became so afraid to speak?

Breaking the Code of Breaking the Code of SilenceSilence Challenged superstition and tradition.Challenged superstition and tradition.

Dared to open the dead, and living, Dared to open the dead, and living, human body.human body.

Believed that even the poor, Believed that even the poor, powerless and diseased deserved powerless and diseased deserved help.help.

Breaking the Code of Breaking the Code of SilenceSilence Over thousands of years, they, we, Over thousands of years, they, we,

learned to use science to stand against learned to use science to stand against time honored (and often wrong) time honored (and often wrong) traditional treatments, based on traditional treatments, based on observations and, initially, on opinions.observations and, initially, on opinions.

Research and education and health Research and education and health systems began with the good ideas of systems began with the good ideas of individuals.individuals.

Breaking the Code of Breaking the Code of SilenceSilence Have we now come full circle? Have we now come full circle?

Does the weight of science or Does the weight of science or popular opinion crush individual popular opinion crush individual objections, individual opinions?objections, individual opinions?

Breaking the Code of Breaking the Code of SilenceSilence In other words, in an evidence based, In other words, in an evidence based,

double-blinded, placebo controlled double-blinded, placebo controlled world, does your opinion matter?world, does your opinion matter?

In a consumer driven, highly regulated In a consumer driven, highly regulated profession, does your opinion matter?profession, does your opinion matter?

Or is your opinion always to be subject Or is your opinion always to be subject to the power of everyone else’s?to the power of everyone else’s?


Is it possible that the opinion of Is it possible that the opinion of one, or a few, can actually be one, or a few, can actually be correct, while the opinion of many correct, while the opinion of many others is wrong? others is wrong?

Breaking the Code of Breaking the Code of SilenceSilence Ever heard of eugenics?Ever heard of eugenics?

Sounded like a good idea.Sounded like a good idea.

Supported by prominent people.Supported by prominent people.

Breaking the Code of Breaking the Code of SilenceSilence Sir Francis Galton, cousin of Sir Francis Galton, cousin of

Charles DarwinCharles Darwin

Alexander Graham BellAlexander Graham Bell

Winston ChurchillWinston Churchill

Breaking the Code of Breaking the Code of SilenceSilence Theodore RooseveltTheodore Roosevelt

Margaret SangerMargaret Sanger

The Rockefeller FoundationThe Rockefeller Foundation

The Carnegie Institute of WashingtonThe Carnegie Institute of Washington

Breaking the Code of Breaking the Code of SilenceSilence And this fellow:And this fellow:


Who incorporated the theories of Who incorporated the theories of eugenics into his racial policies, in eugenics into his racial policies, in order to purify the world.order to purify the world.

Breaking the Code of Breaking the Code of SilenceSilence Some US research funding was Some US research funding was

even involved in the early even involved in the early genocidal activities of Nazi genocidal activities of Nazi Germany.Germany.

Smart people, big corporations, Smart people, big corporations, new ideas, must be good, right?new ideas, must be good, right?

Wrong.Wrong.

Breaking the Code of Breaking the Code of SilenceSilence Are all of us stupider than any Are all of us stupider than any

one of us?one of us?

Breaking the Code of Breaking the Code of SilenceSilence Well, I’ll tell you right now:Well, I’ll tell you right now:

Your opinion matters, even if it’s a Your opinion matters, even if it’s a minority.minority.

This is very important to the future This is very important to the future of medicine, and your fulfillment.of medicine, and your fulfillment.

Breaking the Code of Breaking the Code of SilenceSilence Anecdote gets a bad rap, as if our Anecdote gets a bad rap, as if our

own experiences are false, our own experiences are false, our own eyes blind, our own hands own eyes blind, our own hands numb.numb.

Only collective opinion and Only collective opinion and research seem to matter.research seem to matter.

Breaking the Code of Breaking the Code of SilenceSilence Anecdote, your observations, matter. Anecdote, your observations, matter.

What you do and see, and how you What you do and see, and how you perceive it matters.perceive it matters.

Every patient you see, every Every patient you see, every experience you have, adds ‘data experience you have, adds ‘data points’ to your brain. points’ to your brain.

Every political and social scenario that Every political and social scenario that involves you teaches you.involves you teaches you.

Breaking the Code of Breaking the Code of SilenceSilence In fact, you must never underestimate In fact, you must never underestimate

the power of your own observations.the power of your own observations.

Every practice location has unique Every practice location has unique people, conditions, situations and people, conditions, situations and pathologies.pathologies.

Not every ivory-tower observation Not every ivory-tower observation applies to your hospital, or your practice.applies to your hospital, or your practice.

Breaking the Code of Breaking the Code of SilenceSilence Physicians have often been Physicians have often been

individualists, struggling against individualists, struggling against larger forces.larger forces.

Let’s look at a very tiny sample of Let’s look at a very tiny sample of physicians who stood against physicians who stood against authority.authority.

Breaking the Code of Breaking the Code of SilenceSilence Galen, AD 129-200. Not allowed to Galen, AD 129-200. Not allowed to

dissect humans, so used animals to dissect humans, so used animals to learn about anatomy. Also worked in learn about anatomy. Also worked in a gladiator school. Did brain and eye a gladiator school. Did brain and eye surgery, as well as cataract surgery.surgery, as well as cataract surgery.

Talk about shooting from the hip!Talk about shooting from the hip! Had very few double blinded studies Had very few double blinded studies

to rely on.to rely on.

Breaking the Code of Breaking the Code of SilenceSilence In 1797, Baron Dominique-Jean In 1797, Baron Dominique-Jean

Larrey, Chief Physician for Larrey, Chief Physician for Napolean, developed first Napolean, developed first prehospital system for battlefield prehospital system for battlefield injuries.injuries.

He clearly saw that the men, and He clearly saw that the men, and the army, deserved better. the army, deserved better.

Breaking the Code of Breaking the Code of SilenceSilence Dr. Elizabeth Garrett Anderson, Dr. Elizabeth Garrett Anderson,

LSA, MD,LSA, MD, 1836-1917.1836-1917.

Who was she?Who was she?

Breaking the Code of Breaking the Code of SilenceSilence The 1The 1stst woman to gain a medical woman to gain a medical

qualification in Great Britain. qualification in Great Britain.

She was refused admission to many She was refused admission to many medical schools.medical schools.

Eventually accepted, but for 19 years Eventually accepted, but for 19 years the only woman in the British Medical the only woman in the British Medical Association.Association.

Breaking the Code of Breaking the Code of SilenceSilence We take this for granted. But We take this for granted. But

apparently, the general feeling was apparently, the general feeling was that ovaries and breasts might get in that ovaries and breasts might get in the way of proper medical decision the way of proper medical decision making.making.

How silly! Everyone knows that it’s How silly! Everyone knows that it’s actually make-up and jewelry that are actually make-up and jewelry that are the problem.the problem.

Breaking the Code of Breaking the Code of SilenceSilence Dr. Emily Barringer 1876-1961.Dr. Emily Barringer 1876-1961. First woman to secure a surgical First woman to secure a surgical

residency.residency. What was she thinking?What was she thinking?

Breaking the Code of Breaking the Code of SilenceSilence What lecture would be complete What lecture would be complete

without Sir William Osler?without Sir William Osler?

Breaking the Code of Breaking the Code of SilenceSilence Contrary to popular opinion of the Contrary to popular opinion of the

day, he moved medical training day, he moved medical training from the classroom to the (gasp!) from the classroom to the (gasp!) bedside.bedside.

‘‘If you listen carefully to the If you listen carefully to the patient they will tell you the patient they will tell you the diagnosis.’diagnosis.’

Breaking the Code of Breaking the Code of SilenceSilence Of course, he also invented the Of course, he also invented the

idea of the open-ended, difficult, idea of the open-ended, difficult, ‘live in the hospital’ residency ‘live in the hospital’ residency program.program.

We’ll forgive him for that…We’ll forgive him for that…

It was worth some laughs.It was worth some laughs.

Breaking the Code of Breaking the Code of SilenceSilence Christian Albert Theodor Billroth Christian Albert Theodor Billroth

1829-1894.1829-1894.

11stst Esophagectomy, 1 Esophagectomy, 1stst Laryngectomy.Laryngectomy.

11stst Gastrectomy for gastric cancer Gastrectomy for gastric cancer ‘after many ill-fated attempts.’‘after many ill-fated attempts.’

Breaking the Code of Breaking the Code of SilenceSilence Nearly stoned to death in Vienna Nearly stoned to death in Vienna

when 1when 1stst Gastrectomy patient Gastrectomy patient died after the procedure.died after the procedure.


Doing something new, something Doing something new, something unheard of, often has a price.unheard of, often has a price.

Like firing, banishment, Like firing, banishment, mistreatment or death.mistreatment or death.

Breaking the Code of Breaking the Code of SilenceSilence Ignaz Phillip Semmelweis, 1818-1865.Ignaz Phillip Semmelweis, 1818-1865.

Believed that hand-washing would Believed that hand-washing would drastically reduce deaths in obstetric drastically reduce deaths in obstetric clinics.clinics.

Physicians felt it ‘took too much Physicians felt it ‘took too much work.’work.’

Breaking the Code of Breaking the Code of SilenceSilence Here’s a test question: Here’s a test question:

What is the ‘Semmelweis Reflex?’What is the ‘Semmelweis Reflex?’


‘‘The dismissing or rejecting out of The dismissing or rejecting out of hand of any information, hand of any information, automatically, without thought, automatically, without thought, inspection or experimentation.’inspection or experimentation.’

(Or sometimes, these days, accepting (Or sometimes, these days, accepting information without adequate information without adequate thought).thought).

Breaking the Code of Breaking the Code of SilenceSilence Like this, for instance: ‘It can’t be Like this, for instance: ‘It can’t be

appendicitis, the WBC is normal!’appendicitis, the WBC is normal!’

Or this: ‘Don’t ever give narcotic Or this: ‘Don’t ever give narcotic pain medication to a patient with pain medication to a patient with an acute abdomen.’ (Always let an acute abdomen.’ (Always let them suffer).them suffer).

Breaking the Code of Breaking the Code of SilenceSilence Or this: ‘If you don’t give Or this: ‘If you don’t give

thrombolytics for stroke, you’re thrombolytics for stroke, you’re not doing the right thing! We’re a not doing the right thing! We’re a stroke center, for heaven’s sake!’stroke center, for heaven’s sake!’


After all, if senators and After all, if senators and congressmen think a therapy is congressmen think a therapy is the right one, and if it’s on the right one, and if it’s on WebMD or Oprah, it has to be WebMD or Oprah, it has to be good!good!

Breaking the Code of Breaking the Code of SilenceSilence Fortunately, doctors do ask Fortunately, doctors do ask

questions sometimes.questions sometimes. Like ‘Why can’t I give my patient Like ‘Why can’t I give my patient

morphine while you finish your morphine while you finish your office hours before surgery?’office hours before surgery?’

Or, ‘Maybe we could give tPA for Or, ‘Maybe we could give tPA for strokes, but not quite as often…’strokes, but not quite as often…’

Breaking the Code of Breaking the Code of SilenceSilence See, sometimes a person takes a See, sometimes a person takes a

chance and makes a revolution, chance and makes a revolution, against common practice or against common practice or opinion.opinion.

Like the early heart surgeons.Like the early heart surgeons.

Breaking the Code of Breaking the Code of SilenceSilence In 1966, a white paper by committees In 1966, a white paper by committees

of the National Academy of Sciences, of the National Academy of Sciences, titled ‘Accidental Death and titled ‘Accidental Death and Disability,’Disability,’

Found that 50% of all EMS in America Found that 50% of all EMS in America was performed by 12,000 morticians.was performed by 12,000 morticians.

It began with individuals saying ‘we It began with individuals saying ‘we can do better!’can do better!’

Breaking the Code of Breaking the Code of SilenceSilence Physicians recognized the Physicians recognized the

incredible need for professional incredible need for professional EMS, and a new specialty.EMS, and a new specialty.

Cincinnati General Hospital started Cincinnati General Hospital started the first residency in 1970. the first residency in 1970.

It revolutionized emergency care!It revolutionized emergency care!

Breaking the Code of Breaking the Code of SilenceSilence Here’s another, from my own Here’s another, from my own

world. Not as dramatic, but world. Not as dramatic, but illustrative:illustrative:

Pat Johannes, MD, FACEP.Pat Johannes, MD, FACEP. Director of my group.Director of my group. Looked at SC Blue Cross/Blue Looked at SC Blue Cross/Blue

Shield reimbursement and said Shield reimbursement and said ‘we’ll pass, thanks.’‘we’ll pass, thanks.’

Breaking the Code of Breaking the Code of SilenceSilence Conventional wisdom? You can’t Conventional wisdom? You can’t

decline to accept BC/BS. They’re too decline to accept BC/BS. They’re too big!big!

Not where we live! And soon, other Not where we live! And soon, other groups followed suit.groups followed suit.

Our reimbursement went up from Our reimbursement went up from BC/BS patients.BC/BS patients.

Breaking the Code of Breaking the Code of SilenceSilence We’re still waiting on the BC/BS We’re still waiting on the BC/BS

Ninja’s to come to his house and Ninja’s to come to his house and garrote him.garrote him.

Breaking the Code of Breaking the Code of SilenceSilence Other issues? Over-crowding. For Other issues? Over-crowding. For

years we were saying ‘hey, it’s crowded years we were saying ‘hey, it’s crowded in the ER!’in the ER!’

For years, administrators said, ‘Yeah, For years, administrators said, ‘Yeah, deal with it! We have a hospital to deal with it! We have a hospital to run!’run!’

‘‘Keep the chaos in the ER.’Keep the chaos in the ER.’

Breaking the Code of Breaking the Code of SilenceSilence We knew it was a problem.We knew it was a problem.

Guess what? It is! And now, Guess what? It is! And now, thanks to daring thinkers in our thanks to daring thinkers in our specialty, hospitals have to deal specialty, hospitals have to deal with the problem as a whole.with the problem as a whole.

Breaking the Code of Breaking the Code of SilenceSilence Here’s the thing: you may not all Here’s the thing: you may not all

be researchers, academics or be researchers, academics or administrators.administrators.

But you can be mavericks But you can be mavericks wherever you practice. You can wherever you practice. You can change things for the better.change things for the better.

Breaking the Code of Breaking the Code of SilenceSilence But only if you’re both honest and But only if you’re both honest and

courageous.courageous.

You could change the face of You could change the face of emergency medicine from emergency medicine from wherever you find yourself.wherever you find yourself.

Breaking the Code of Breaking the Code of SilenceSilence But you can’t simply conform.But you can’t simply conform.

Breaking the Code of Breaking the Code of SilenceSilence What other controversies has our What other controversies has our

specialty faced?specialty faced?

How about fair group practices?How about fair group practices?

Conventional wisdom says, ‘I own Conventional wisdom says, ‘I own the contract, I get the money, you the contract, I get the money, you get the holidays!’get the holidays!’

Breaking the Code of Breaking the Code of SilenceSilence The founders of AAEM led the The founders of AAEM led the

charge, and today the landscape is charge, and today the landscape is different in emergency medicine.different in emergency medicine.

Not perfect, but different.Not perfect, but different.

Because someone was willing to Because someone was willing to challenge the status quo.challenge the status quo.

Breaking the Code of Breaking the Code of SilenceSilence It applies in large issues and It applies in large issues and

small:small:

You must lavage all overdoses!You must lavage all overdoses!

Then, you must give charcoal to Then, you must give charcoal to all overdoses.all overdoses.

Breaking the Code of Breaking the Code of SilenceSilence Most of us who saw them realized Most of us who saw them realized

something:something:

They fell asleep, we intubated They fell asleep, we intubated them, they woke up angry, they them, they woke up angry, they signed out AMA.signed out AMA.

No matter what we did!No matter what we did!

Breaking the Code of Breaking the Code of SilenceSilence Now we know that it was a Now we know that it was a

reasonable thing to do in most reasonable thing to do in most overdoses.overdoses.

Protect their airway. And…Protect their airway. And…

‘‘Don’t just do something, stand Don’t just do something, stand there!’there!’

Breaking the Code of Breaking the Code of SilenceSilence My point is simply that our opinion, My point is simply that our opinion,

gathered from experience, is vital.gathered from experience, is vital.

Research fluctuates, research can be Research fluctuates, research can be well done or poorly done, industry well done or poorly done, industry driven or not.driven or not.

The Hawthorne Effect is a real concern.The Hawthorne Effect is a real concern.

Breaking the Code of Breaking the Code of SilenceSilence Rib belts good, rib belts bad, rib Rib belts good, rib belts bad, rib

belts good…belts good…

Computers in medicine will Computers in medicine will reduce errors…or maybe increase reduce errors…or maybe increase themthem

Breaking the Code of Breaking the Code of SilenceSilence Privacy needs to be protected!Privacy needs to be protected!

Passwords are a pain in the bottom.Passwords are a pain in the bottom.

Computerized records are great.Computerized records are great.

Computerized records may Computerized records may deteriorate.deteriorate.

Breaking the Code of Breaking the Code of SilenceSilence Black Box warning for Inapsine!Black Box warning for Inapsine!

We have to stop using a We have to stop using a dangerous drug!dangerous drug!

Oh, heck, we’ll use it anyway Oh, heck, we’ll use it anyway because it is actually pretty safe.because it is actually pretty safe.

Breaking the Code of Breaking the Code of SilenceSilence Soft cervical collars, rib belts, Soft cervical collars, rib belts,

sterile suture technique, ATLS sterile suture technique, ATLS guidelines, ACLS guidelines.guidelines, ACLS guidelines.

The list goes on and on.The list goes on and on.

Research, critical to our work, is Research, critical to our work, is always changing.always changing.

Breaking the Code of Breaking the Code of SilenceSilence There are large and small issues There are large and small issues

we need to face courageously.we need to face courageously.

What about the ‘Customer Service’ What about the ‘Customer Service’ mentality of modern medicine?mentality of modern medicine?

Is it the right thing, or the wrong Is it the right thing, or the wrong thing?thing?

Breaking the Code of Breaking the Code of SilenceSilence My contention is that if you don’t My contention is that if you don’t

pay for a thing, you cease to be a pay for a thing, you cease to be a customer.customer.

‘‘Customer’ has a different ethical Customer’ has a different ethical and moral obligation from and moral obligation from ‘patient’.‘patient’.

Breaking the Code of Breaking the Code of SilenceSilence Patient satisfaction surveys are Patient satisfaction surveys are

also suspect.also suspect.

But we do them anyway, and But we do them anyway, and doctors are afraid of them, so do doctors are afraid of them, so do things they might not otherwise do.things they might not otherwise do.

Is this wise? Is this good medicine?Is this wise? Is this good medicine?

Breaking the Code of Breaking the Code of SilenceSilence Does it make us better doctors to Does it make us better doctors to

offer free movie tickets to offer free movie tickets to patients who wait too long?patients who wait too long?

Breaking the Code of Breaking the Code of SilenceSilence Some suggest that we have no Some suggest that we have no

waiting room.waiting room.

Do we need a waiting room?Do we need a waiting room?

Are we bad doctors if someone has Are we bad doctors if someone has to wait two hours for a hangnail?to wait two hours for a hangnail?

Breaking the Code of Breaking the Code of SilenceSilence The treatment of chronic pain and The treatment of chronic pain and

acute pain.acute pain.

Does the pain scale supplant my Does the pain scale supplant my years of experience?years of experience?

Does JCAHO know how to treat the Does JCAHO know how to treat the sick?sick?

Breaking the Code of Breaking the Code of SilenceSilence Did the IOM report on error make us Did the IOM report on error make us

more careful? more careful?

Are we really killing all of those people, Are we really killing all of those people, or were many of them already dying?or were many of them already dying?

Maybe we are, but is it reasonable to Maybe we are, but is it reasonable to ask?ask?

Breaking the Code of Breaking the Code of SilenceSilence Not everyone thinks we should Not everyone thinks we should

ask.ask.

Many think we should simply Many think we should simply apologize and make every effort apologize and make every effort to look better for our customers.to look better for our customers.

Breaking the Code of Breaking the Code of SilenceSilence In order to look better for the In order to look better for the

public, along came the public, along came the LLSA/Concert Exam.LLSA/Concert Exam.

Rather than hire a PR firm to Rather than hire a PR firm to counter charges of our counter charges of our ‘incompetence’, we said, ‘Oh ‘incompetence’, we said, ‘Oh what can we do?’what can we do?’

Breaking the Code of Breaking the Code of SilenceSilence Believe it or not, I have it on good Believe it or not, I have it on good

sources that there was contention sources that there was contention between ACEP and ABEM about the between ACEP and ABEM about the LLSA idea.LLSA idea.

Physicians in practice, who have to Physicians in practice, who have to pay the fees, read the articles and pay the fees, read the articles and take the tests, believe it won’t help take the tests, believe it won’t help them.them.

Breaking the Code of Breaking the Code of SilenceSilence Trust me when I say, people are Trust me when I say, people are

still upset.still upset.

And so is ABEM. The ABEM And so is ABEM. The ABEM president called me at home.president called me at home.

Yikes.Yikes.

Breaking the Code of Breaking the Code of SilenceSilence What about the idea that you What about the idea that you

have to be in a teaching center to have to be in a teaching center to practice good medicine?practice good medicine?

That you have to be on 12 That you have to be on 12 committees, work with 2 EMS committees, work with 2 EMS services, and teach medical services, and teach medical students, in order to be a good students, in order to be a good doc?doc?

Breaking the Code of Breaking the Code of SilenceSilence What about the fallacy that you What about the fallacy that you

can get filthy rich in Emergency can get filthy rich in Emergency Medicine?Medicine?

What about the idea that maybe What about the idea that maybe you could use your flexibility to you could use your flexibility to know your spouse and children?know your spouse and children?

Breaking the Code of Breaking the Code of SilenceSilence Whether you are in a position of Whether you are in a position of

authority, or just work in a small authority, or just work in a small hospital, don’t be afraid to hospital, don’t be afraid to question the status quo.question the status quo.

By your very education, your By your very education, your practice, your love of people, you practice, your love of people, you have more knowledge than you have more knowledge than you can imagine.can imagine.

Breaking the Code of Breaking the Code of SilenceSilence So never be afraid to speak, or So never be afraid to speak, or

ask, or dissent.ask, or dissent.

Do it with respect, and with Do it with respect, and with honesty.honesty.

Do it without rage or profanity.Do it without rage or profanity.

Breaking the Code of Breaking the Code of SilenceSilence And if you are in a position of And if you are in a position of

authority, teaching, researching, authority, teaching, researching, managing, learn to listen to the managing, learn to listen to the ‘unimportant’ people.‘unimportant’ people.

They might have a really good They might have a really good idea.idea.

Breaking the Code of Breaking the Code of SilenceSilence But whatever you do, honor your But whatever you do, honor your

medical ancestors, and those who medical ancestors, and those who gave you free speech, and refuse gave you free speech, and refuse to be silent when you see to be silent when you see something, clinical or non-clinical, something, clinical or non-clinical, that needs to be questioned or that needs to be questioned or changed.changed.

Breaking the Code of Breaking the Code of SilenceSilence If you don’t, you dishonor the If you don’t, you dishonor the

past and silence the future.past and silence the future.

Breaking the Code of Breaking the Code of SilenceSilence Thanks for letting me visit.Thanks for letting me visit.

It’s an honor to speak to old It’s an honor to speak to old friends and new.friends and new.

Visit my website sometime:Visit my website sometime: www.edwinleap.com.www.edwinleap.com.

Health & Medicine

Speaking Your Mind