Command of a tight ship stays out of reach

My wife and I recently visited Las Vegas for the first time. We went with a large group of friends to celebrate one of them turning 40. We had a great time. Each night, we would party with the group, and during the day we were on our own. I have learned over the years that I don't gamble, I just give money away to whoever else is playing, so most days Deana and I avoided casinos and went hiking with friends.

On a trip to the Valley of Fire, our group included an ER doc, an internist, a lawyer, and an insurance executive. No, this isn't a lead-in to a lifeboat joke, we actually had an interesting discussion about physician dissatisfaction with the healthcare system. The heart of the matter came down to the difference between responsibility and authority.

A technologist or a nurse who is really on the ball can make your day. One with an attitude can ruin it. Most nurses and technologists I work with are nice, capable people. But we've all run into ones we just can't get along with. Maybe they are too slow for my pace, or too fast. Maybe they think they know far more about the procedure we are doing than I think they know. Maybe their spouse left them last night, and they are miserable. Maybe they think I'm a whiner.

Whatever the reason, they are doing things their way, not mine. I may complain to admin, but if no real harm has been done, real action is seldom taken. A radiologist who regularly points out that things are not being done his or her way is a "complainer." Unfortunately, this often creates even more attitude problems.

All this angst is of academic interest until someone gets hurt or a procedure is done wrong. Suddenly, everyone insists they were doing it my way, by the book, like they always do. A team of QA nurses soon swarms like flies on dung, dreaming up elaborate new protocols to replace mine, since mine caused this patient mishap. Reasons for the misadventure will be detailed at length, but I have never read one report that mentioned attitude and personality conflicts.

In the end, I am responsible. People working with me, whom I am essentially powerless to control, made an error for which I am responsible. In the Navy, the commanding officer of our ship was ultimately responsible for any mishap, but not doing things his way usually got you a fine or confinement. I can order neither, but I'm equally responsible. You're not surprised, because you deal with this everyday.

What I found interesting in our discussion was how shocked the lawyer and the insurance exec were when all three physicians gave examples of this problem: an ER nurse who screens patients her way, a pharmacist who questions every drug order, and so on. They were truly amazed that hospital employees might not do exactly what we wanted-intentionally. And that if we complain too loudly, we are the malcontents.

They could not imagine how we could tolerate or accept this situation. The three of us agreed that there really is no alternative. This is how hospital medicine works. And this is why physicians are retiring younger than ever, and in greater numbers than ever.

When I entered medicine, physicians were the authority in most healthcare decisions, and they accepted responsibility for the results. Since then, we have seen a constant decline in our authority, but not in our responsibility.

Later that night, I think we continued the conversation over drinks, while I gave money to a very nice dealer. For-tunately, I don't remember too many details from the nights out there.

Dr. Tipler is a private-practice radiologist in Staunton, VA. He can be reached by fax at 540/332-4491 or by e-mail at btipler@medicaltees.com.