Cui Bono and the Electrocardiogram

Abstract

Between the idea And the reality, Between the motion And the act Between the potency And the existence … Falls the Shadow — T. S. Eliot cui bono–Latin phrase meaning “Who benefits?” At 5 a.m. I was notified that a patient in a continuing care retirement community (CCRC) had been in moderate respiratory distress for 3 hours despite a nebulizer treatment. The patient had a history of chronic obstructive pulmonary disease, ischemic cardiomyopathy, permanent pacemaker insertion for sick sinus syndrome, and chronic anemia. I suggested transfer to the emergency department, but the patient, who possessed decision-making capacity, refused. I then decided to make an emergency visit and asked the nurse to perform “the electrocardiogram (EKG)” while I was en route. I acknowledged a recent corporate directive banning nursing from performing EKGs with the existing CCRC machines but felt the circumstances warranted my order. The nurse concurred. (This CCRC had been the sole one in the corporation where nurses performed EKGs, and to maintain corporate conformity, EKG performance was out-sourced. After the decision, the attending physicians noted that hundreds of patients had been treated safely in the CCRC setting under the prior 29-year policy and that out-sourced EKGs would result in unnecessary patient transfers to the emergency department.) When I arrived, the patient was still in moderate respiratory distress, and the EKG revealed new T-wave inversions throughout the precordium. After my examination, I explained the medical possibilities to the patient and recommended transfer to the emergency department. The patient agreed and was hospitalized with an acute myocardial infarction and congestive heart failure. One month later, I was summoned to a meeting with the administration and was told per corporate policy I had unacceptably asked the nurse to perform “the EKG.” I was asked to resign; if I refused, my medical privileges would be revoked. After I defended my decisions in the light of my physician–patient covenantal responsibilities, the administration acknowledged my dilemma, but they still felt that I was bound by corporate policy. For 24 years, I had been an attending geriatrician at this CCRC, where the physicians had played major roles in the development of flexible interdisciplinary policies to meet the unique needs of their elderly patients and healthcare team. Six years before “the EKG,” those roles and their focus changed when the CCRC merged with a corporation whose regulatory-centered governance replaced existing policies with rigid and uniform corporate versions and continued the implementation of new medical policies, all by corporate fiat. When I frequently voiced my concerns over the lack of physician input and the inflexibility of the corporate medical policies, the administration maintained that the provision of quality health care throughout the corporation required strict adherence to uniform corporate policies. The circumstances surrounding “the EKG” convinced me that my time as an attending geriatrician at this CCRC had passed. I would always see the shadow born of the inherent complexities of practicing geriatric medicine; “the EKG” and a flexible interdisciplinary philosophy as pathways to real-time decision-making; and the answer to cui bono to be “the patient.” The administration would continue to see the certitude of monolithic corporate policies; “the EKG” and noncorporate adaptations as forbidden fruit; and the answer to cui bono to be “corporate conformity.” So I agreed to resign. On my last day, a fellow geriatrician gave me the picture, Morning Rounds, by Terry Redlin. The painting depicts a country doctor as he begins rounds at sunrise, driving a workhorse-drawn buggy east on a winding dirt road. On the right in the shadows are a home and possibly a church and mill. The sun rises in brilliant oranges and yellows in the left lower corner as the approaching horse, buggy, and physician are beginning to be bathed in sunlight. The painting rekindled my spirit, and I continue to be a geriatrician despite governmental and corporate policies that make the practice of geriatric medicine difficult. As we begin our rounds each day, we should turn to the light, energy, and comfort of medicine's raison d'être, to continually attempt to relieve and prevent human suffering, because it will provide us the necessary strength to combine science, compassion, and responsibility with the principles of “first do no harm,” beneficence, and cui bono, as we tend to those who call us doctor. As for the policy makers, the patient care covenant requires that they occasionally accompany us on our “morning” rounds. Indeed, they might learn something before they themselves get old and sick. Financial Disclosure: None. Author Contributions: Ward Becker was the sole contributor. Sponsor's Role: No sponsor.