Find your tribe.

Choosing a specialty is a funny old thing.

We spend a lot of time in medical school, and post graduation, trying to decide which area of Medicine we are suited to. It is an important decision, as it decides your career path and length of training, and although there is some potential for movement, it often entails further years in training if you get halfway down one path and decide you would rather be on another.

Some people are fortunate enough to be certain in their career aspirations, and know which path they want to pursue. I was never like that. I have found myself ambivalent about the specifics of Medicine. Nothing particularly excites or drives me more than anything else. I am generally doing the job because it seems a waste of a medical school education to do anything else.

It is bizarre then, that I have chosen Emergency Medicine. Ostensibly, this is the most stressful, involved, high pressured area of Medicine. You have to know lots about lots of things and for someone unexcited by various aspects of medicine, seeing patient after patient with a cough or a toe injury or a rash is hardly enthusing. Intersperse that with the seriously unwell patients who keep attempting to die on you, and on paper it sounds even less like something I would enjoy doing.

But the people. My God, the people. I remember walking into my first ED job, seeing the nurse in charge rip the shit out of the on call doctor with a crass and frankly too easy joke, and thinking “I have found my tribe.”

I firmly believe that it is not the type of job that you need to base your career decision on, but the type of people you will have to work with. And there is no better bunch than the ED team. Nowhere else in the hospital do nurses and doctors work so closely together. The relationship can be beautiful. You have the opportunity to understand each other, and ED teams become like family (a replacement for the family you have at home that you never see due to an unforgiving rota).

I have just finished a shift where it would be understandable if I was a broken person going home. Presentations were relentless, the board was out of control, not enough doctors, too few nurses, several angry patients – the usual ED shift. But instead, it was one of the better days I’ve had in a while. My personal life is a little rubbish at the moment and it is nice to be able to come into work, and have a good laugh with a genuinely great group of people. You don’t go into Emergency Medicine unless you are hardworking, sarcastic, fun, and have a thick skin.

I am in my 3rd year of ED training now, and during those years I have had to spend several months out of the department getting experience in other areas of medicine. And each time I have come back to ED I have felt the same sense of relief. Mainly the relief of no more ward rounds, no more clinics, and no more dealing with patients for longer than 4 hours (I have a ridiculously short attention span)! But also happiness that however rubbish the shift, however overworked, underpaid, generally under appreciated we all are, there will be piss-taking and merriment, and, if I have had time the night before, homemade cakes and biscuits. You can’t ask for more than that.

Welcome to A&E

confessionsofajuniordoctor:

I have no idea what it is that I like about Emergency Medicine.

The hours are terrible. The rota is indecipherable. You cannot plan to attend a friend’s birthday or a family gathering. Your social life is non-existent. The patients are largely rude, drunk, smelly and irreverent. There are never enough staff on shift. The urgent care centre referrals are sometimes ludicrous. The GPs send in UTIs as renal colic, PID as appendicitis, persistent patients that they can no longer placate. The specialty doctors think we are either lazy or lobotomised. You spend more time than you should at the centre of “specialty tennis”.

The four hour wait is a travesty. There are never enough observation beds. The pressure is immense. The clock never stops. There is always another patient waiting, another test to order, another result to check. There is always a diagnosis to be made, and treatment to initiate, a conversation to be had. You go from renal colic to brain tumours to heart attacks. You see depressed people, drunk people, old people, children. You see people at their worst. You see time wasters and hypochondriacs and then sepsis and deaths. You don’t have time to process. You don’t have time to think. You see, treat, refer, discharge.

People complain about the waiting time, disagree with your assessment, believe google before they believe you. You go home at night paranoid about the patient you sent home; constantly questioning your decisions, your abilities and your sanity. You see multiple patients simultaneously, you are a porter, a nurse, a cleaner, a friend, a confidant. You tell people good news, bad news, sad news.

You are charged with the unhappy job of treating people’s liver disease from excessive alcohol, lung disease from smoking, diabetes from overindulgence. People expect you to take responsibility for their lifestyle choices. You endure the abusive drunkards, the psychotic schizophrenics, the deranged elderly. You put up with the people who have neither an accident nor an emergency.

You exhaust yourself looking after these people, so much so that you go without food, without bathroom breaks, without the most basic of human needs. You are vilified by the media, who feel you are paid too much for what you do. You are misunderstood by friends and family who watch too much ER and Casualty. You become unacceptably irked by poor resuscitation techniques on TV shows. You complain about unnecessary attendances and then carry out wholly unwarranted tests because you are scared of being sued. You will inevitably have complaints filed against you for merely doing your job. You will make poor management decisions and people will die. You will make excellent management decisions and people will still die. You will defy the odds: CPR will work; the patient will recover from sepsis; be discharged from hospital, and then die at home a week later.

You will miss things. You will be wrong on a daily basis. Everyone thinks they know more than you. You finish a shift and barely have the energy to walk to the car; let alone drive home. You spend at least half of your days off comatose in bed. You don’t see your housemates for weeks due to opposing shift patterns. You do locum shifts during your time off because there are never enough doctors and you know how awful it is to work when they’re short staffed. The barista at Costa knows what sort of day you’re having based on whether you order a medio cappuccino or a double espresso. The packed lunch you brought 3 days ago is still sat in the refrigerator. Once you leave work you are unable to make the smallest of decisions because you have used up all of your brain cells.

You are stressed out, overworked and rarely thanked. And I can’t think of any specialty that I would enjoy more.

I wrote this post over a year ago. I am now back in ED as a specialty trainee, and the above is just as true as it has ever been.

I have loved this job in the face of so many reasons not to, and it will take more than contract changes or incompetent health secretaries to change that. Do your worst Jeremy, we will be doing our jobs long after you have finished doing yours.

This is a red NEWS call to AMU

Yesterday I collapsed in the treatment room in A&E.

I was working my third consecutive 13-hour shift over a bank holiday weekend. I was running a fever of 39 degrees and had the most horrendous head cold. I was probably sicker than at least 20% of the patients I was being asked to admit to hospital. I was the only SHO on shift for medicine, and when I had awoken with blocked sinuses, the inability to stand upright without staggering, and the full knowledge that realistically I should spend the day horizontal, slipping in and out of sleep and having hot ribenas, it did not even cross my mind to call in sick.

I am not writing this for sympathy. I know an overwhelming amount of people who have done the same thing. As medical professionals, we consistently prioritise other people’s needs above our own. It is part of the job. However, yesterday I was unsafe. I could barely walk, let alone be expected to make a legitimate management decision for a patient. I drugged myself up on a combination of co-codamol and nurofen, and wandered the hospital with a box of tissues and a litre of ribena.  In my mind, there was no other option. Bank holidays and weekends run on skeleton staff – the number of doctors to patients is dangerous even when everyone is on top of their game. You have to be legitimately dying to justify staying home.

Bank holidays in particular also tend to run on locum staff, particularly locum registrars. Now, whilst some of these are amazing doctors, most aren’t. Even if they are good clinically, they usually don’t know the hospital layout, don’t have access to the reporting systems, don’t know how to request imaging. It makes an already stressful shift unbearable when they don’t even have good clinical skills. My registrar on Friday did not recognize when a patient went into ventricular tachycardia on a monitor, and it was only because I happened to walk behind her that we managed to check if the patient had a pulse, start him on the correct medication and take him to CCU. How could I call in sick when I knew what state I was leaving the on call team in?

Things like updating families about patient’s conditions go by the wayside. Urgent blood tests get handed over from day team to night team and back again. Once you have been clerked in on an acute take you are lucky if you see a doctor at all until the next normal working day – if you are unlucky enough to be admitted on Good Friday then you can usually expect to sit idle, with no further medical assessment until 4 days later.

The only thing that alerts us to a patient’s deterioration is the NEWS call – a call put out when a combination of a patient’s blood pressure, heart rate, temperature and oxygenation reaches dangerous levels. These calls mean we have to come running to the ward, quite often for things that could easily have been avoided if there were enough staff to reassess a patient’s condition on a regular basis.

It is baffling to me that not more people die over long weekends in hospital. If you make it to the end of a shift without an “adverse outcome” it feels like it is more a result of luck than anything else. If we had even one more doctor on shift it would feel less unsafe. I know multiple doctors who would rather work twice the number of on calls with adequate staffing than half the number and feel unsafe. But I know it is all about money. We seem to have an endless pot to fund terrible locum doctors at the drop of a hat, but never enough left over to create a more tenable working rota, which would hopefully decrease the need for the locums in the first place. 

And meanwhile, people like me come into work dangerously unwell, and then take up a bed in ED for assessment – further adding to the workload of an already overstretched system.

A&E as a symptom, not the disease.

WARNING
This is a long, boring post on the difficulties facing A&E in the current climate. Complete with the disclaimer that my views are entirely my own and should not be used to represent any organisation that I work for yadda yadda yadda….

ED (as A&E was renamed years ago, in the hope of cutting down the number of accidents that present there that are neither life-threatening, nor emergencies) has become somewhat of a hot topic.

Not a surprise: it is a hugely political system, and we are in an election year. Labour MPs are decrying the Tories’ management of EDs, stating that they have “betrayed patients”; David Cameron has made several glib remarks about EDs being busy, but coping “heroically”, there has been much talk about failure and little offer of solutions. This is because we are focussing on the wrong problem.

Increased waiting times and poor performance in EDs are a symptom of failure of our healthcare system at a much deeper level. The issues are admittedly most obvious when you are sat waiting 5 hours to see a doctor with a broken hip or a breathing problem. However, the root cause of this wait is not solely based on occurrences in ED, nor in a failure of pre-hospital systems to avoid unnecessary admissions.

Below is a brief outline of some of the major factors involved in the ED crisis.

  1. Inappropriate access of services:

    Despite what the media will have you believe, inappropriate presentations to Emergency Departments are not a direct result of lazy GPs. Most A&E attendances occur between 9-5, when people’s local GP surgeries are open, often with specifically designated emergency appointments available. It is interesting to note that a patient’s impression that they “would not be able to get a GP appointment” is not proof that they have actually tried. We have the media to thank for this one.

    Additionally, advice helplines such as 111 make a valiant effort to point people in the right direction. However, it is incredibly difficult to accurately assess someone over the phone, and they largely err on the side of caution and send people unnecessarily through to ED. This is obviously preferable to the alternative end of the spectrum, but again clogs up the Emergency Department unnecessarily.

    Patients do not understand that the ED cannot help you with all medical problems. I would see many people who presented due to (perceived) lack of access to their GP, with stable conditions that needed outpatient investigation. Thanks to the NHS restructuring, putting the burden of budgeting onto GPs, we are no longer allowed to refer in to clinics from ED, and as a result the poor patient has had a wasted trip, an unnecessary 4 hour wait, increased the waiting time for others in the department who may actually require emergency care, and has to go to their GP in the end anyway.

  2. Social care funding:

    Cuts to social care funding have led to less support for people at home. Vulnerable adults are therefore left without vital support and end up presenting to ED with entirely preventable falls, infections, and loneliness.

    Outreach community services such as district nurses are under increasing pressure. In a report published last year, the Royal College of Nursing cited great difficulty recruiting nurses to these roles. The numbers of nurses are decreasing at a time when the demand for their services is exponentially rising. Patients presenting to ED with dressings that need changing, catheters that need unblocking are entirely preventable with good community care.

  3. “Bed blocking”

    A significant contributor to increased waiting times in ED is the lack of available beds in which to put the 1 in 5 attendees that are admitted to hospital. This is due to a number of factors, not least:

    Out of Hours investigations (or lack of). Patients admitted to hospitals acutely are often stabilised and managed within 24-48 hours. The remaining tests could often be done as an outpatient – things like CT scans and 24-hour tapes. However, it frequently takes a millennium to arrange these tests once someone has left hospital. As a result, relatively stable people stay longer in order to get faster access to specialist tests. Additionally, when people are admitted on a Friday night, they regularly have to wait until Monday morning for a specific investigation, or to see a Consultant specialist, which clogs up beds.

    Delayed discharges. These are due to many factors – patients admitted with acute medical problems are often found unable to cope at home, with discharge back to their pre-admission state impossible. In-hospital teams such as Physiotherapy, Occupational Therapy, Speech and Language etc. are amazing, but implementing the much-needed changes takes a huge amount of time. Most of this is due to workload, and the difficulty liaising between hospital care and community services. Social service teams are frequently understaffed and over-worked, and when someone requires state funding for home adaptations or care packages they might as well spend the rest of their lives in hospital.

  4. Lack of senior staff and training doctors:

    Although, as I said above, there is too much attributed to the levels of staffing in ED, there is not enough recognition of lack of senior nurses and doctors in training. The importance of this cannot be overstated. Having a Consultant triaging attendances with the experience necessary to stream patients without waiting for investigations is vital. Having experienced nurses ordering the necessary tests before the doctors see the patient avoids pointless delays whilst you await blood tests and other investigations. Having a higher number of registrars and consultants as compared to junior doctors means better and faster decision-making.

    Having doctors in training and nurses on contracts is greatly beneficial to a smoothly run department. The reliance on locum doctors and bank nursing staff means that not only is there less of a team mentality, but there is also a lack of knowledge about how the specific hospital operates. Teaching a new nurse where to locate equipment, how to find the IV medications, where to put the CAS cards when they have done an assessment wastes valuable time. Showing locum doctors how to use the computers, where to assess patients, how to refer to specialty teams wastes valuable time. Doing this over and over, day in day out is exhausting for all involved.

  5. Lack of responsibility for our own medical conditions:

    There has been a huge drive forward in recent years with regards to health education. We can no longer say that we are unaware of the dangers of smoking, drinking, over-eating, doing next to no exercise, and using recreational drugs. Our jobs as health professionals is to give people the best possible information about how to live as long and as well as they can. It is up to them how much heed they pay us. I have no problem with people choosing to ignore us – I do most of the above list myself. However, we cannot expect our poor healthcare system to pick up the slack for us. We do not have the right to act surprised when we turn up at an ED unable to breathe/with liver failure/diabetes. We give ourselves complex diseases, which are costly in both money and time to treat, and we clog up Emergency Departments due to our own lifestyle choices. We then complain about how long we have had to wait.

  6. A&E as a political football:

    A&E is the most easily measurable indicator of how the NHS is functioning as a whole. The 4-hour target, for good or bad, gives a readily accessible measurement for performance across trusts. The NHS is a great source of national pride; we still have the impression that our healthcare system is the best in the world, unique in its vision to offer free at point of service healthcare to all. This is false. However, as a result of this, the NHS is a huge political item. In the lead up to our election year, we will no doubt hear many more ludicrous statements about how best to manage the NHS, and inevitably how best to operate our Emergency Departments. We don’t leave one system alone long enough to accurately assess its efficacy. As doctors, we are simply trying to do our jobs, treat as many people as humanly possible, and do the best we can for our patients. We can do without the vague political platitudes that exalt us for doing “heroic work” in the face of extreme pressure. We don’t do it for the glory. We need practical change, implementation of legitimate management plans to increase social care funding, to incentivise substantive A&E training posts, to improve communication between primary and secondary care, to aid discharges into the community, to offer 7 days a week scanning, to have proper Consultant cover on the weekends, to employ more district nurses, paramedics, therapists.

There is so much that could be changed for the better. There are so many factors affecting our hospitals, our A&Es, our NHS. Pick one, and move on from there. Stop disagreeing with politicians from different parties for the sake of it. Stop reveling in the disappointments of others. Fix our damn healthcare system before it is too late.

End rant.

Doctor, your patient is going to breach…

Last week saw the “worst week in A&E” since monitoring began in 2010.

Much has been made in the media about the number of people breaching the four-hour target. There is also a shocking lack of understanding of what the four-hour target actually means.

The target is not for patients to be seen by a doctor in four hours. The target involves patients being booked in at the front desk, assessed by nurses, triaged by frontline Consultants, having blood tests and other investigations performed, being fully clerked and examined by another doctor, having a diagnosis made, being referred to a specialty team, and then leaving the department to go to a bed on the ward, or being discharged home.

I don’t have to point out that the potential for delay here is almost unquantifiable.

During my shifts in ED I would frequently pick up patients who had twenty minutes to go. I would sometimes pick up patients who had already breached. Usually, these patients had been streamed to the urgent care centre, and then referred on to ED. Because it is technically the same department, they come through on the same clock… So, from the point of view of the four-hour target, we have failed before we have even started.

The target has good and bad points. It is an arbitrary, statistically useful but morally obsolete tool, to aid us in defining our parameters and assessing our performance. It is as useful or useless as any predetermined timeframe, and the number itself is not the issue. The problem occurs due to the fixation on the target above other priorities. Used properly, the target helps us identify areas of weakness, and departments that are struggling to see their patients safely. In an ideal world, departments with more breaches should get more funding, for higher staffing levels, for increased number of observation beds, for larger majors areas. In reality, breaching leads to stressful conditions, forced decision-making, and compromised patient safety.

There are a few funny internet memes floating around about the ED. One of them states “save three people’s lives and no one bats an eyelid; breach one patient and all hell breaks loose.” I have been blessed with working in an ED where there are excellent working relationships amongst the staff, and patient safety is consistently a priority. Even so, I have often felt pressured to make a quicker decision about a patient, to take down the half bag of saline still running, to amend the timing of my medical entries in order to have one less breach.

Quite often, the balance of admission or discharge in ED hinges on a period of observation. It is impossible to accurately assess a patient’s condition in 20 minutes. The luxury of allowing them to sit in the department, with regular observations, and pain relief/a bag of fluids is often all that is needed to avoid an acute admission. Where I am working currently, they have recently reduced the number of ED observation beds from 20 to 4. This is in order to build a much-needed Acute Medical Unit, which in turn helps free up the ED by providing an exit strategy for medically accepted patients. However, this has significantly reduced the number of people we can observe prior to admission. These people are now sat on the AMU, occupying the beds that they would have occupied on an observation ward, only now they are being clerked by an additional team; there is a whole host of admission paperwork; and they will inevitably stay overnight, costing the NHS an additional £600 per patient.

The media is making much of the fact that higher ED attendances are leading to overcrowding and pressures on departments. This is only partially true. Yes, there has been a steady, expected increase in attendance leading up to winter. However, the total number of ED attendances in the “worst week”, were actually lower, nationally, than a comparative week in July of this year. So why the inability to cope?

Frequently, the reason for the backlog is the occupation of ED beds and trolleys by patients who have already been referred to specialties, but are either too unstable to transfer, or there are no beds on the ward. Obviously, if someone needs monitoring, and the only monitored bed is in Resus, then we are not going to chuck them out just because they are at 4:01. This has its own issues – what do you do with these patients when you have another blue light come in?

There have been so many headlines over the past few weeks:

A&E forced to turn away patients; Patients waiting 24 hours to be seen in A&E(!); A&E closures: the meltdown…

It doesn’t take much assessment to realise that when you close down an ED, the patients that would usually attend there will need to be seen somewhere else. And yet, it seems to have come as a massive surprise to everybody that in the wake of the closure of Hammersmith ED, the surrounding hospitals have seen increased waiting times, and Northwick Park Hospital has almost consistently been on divert, causing ambulance crews to telephone ahead and take patients to other EDs in the area. 

I am a huge proponent of closing dysfunctional departments. Having worked in a failing DGH last year, I strongly feel that no ED is better than a failing ED. However, there seems to have been no foresight with the closures, and the government very much seems to be expecting existing departments to pick up the slack with no extra room, resources, or staff. Yes, there are planned improvements to the services under strain, but it all feel a little perfunctory, and will likely be too little too late. Northwick Park’s escalation measures involve turning corridors into patient beds; this is not a sustainable situation.

The College of Emergency Medicine has produced several recommendations for fixing our ailing EDs. One of these is the STEP programme, which is basically common sense. It states that there needs to be higher staffing levels, more inpatient beds to free up ED assessment trolleys, and better access to, and knowledge of, primary care services. All of this feels a little obvious, and one wonders why there is less about how we can implement this in the media. But, I suppose, it makes a less catchy headline than “A&E 4 hour wait crisis”.

“Each man is capable of doing one thing well. If he attempts several, he will fail to achieve distinction in any.” Plato

It is interesting that general belief appears to be that the NHS is an anomaly. A shining beacon of socialism with the rare quality of providing healthcare for all, regardless of income. In 1948, this was definitely true. In a post-war era, the founding of the NHS was a spectacular leap forward.

I found it faintly baffling in the Olympic Opening Ceremony, when we devoted a significant portion of the proceedings to the founding of the NHS. It underlines the national feeling of pride about our healthcare system, and an assumption that other countries are not as fortunate. This is false: almost every other developed country has a comparable system. Some are taxation based, some work on compulsory insurance, but the general principle of universal healthcare unrelated to income is now implemented across Europe and the developed world. 

It is the misconceptions about our healthcare system, both about ideology and practicality, that lead to the discrepancies of opinion between public demand and system reform. There is a general feeling that reorganisation and specialisation are undermining the ethos of our healthcare system. There is public disgruntlement about local hospital closures and apparent diminishing services in district hospitals.

I have completed almost a year working at Ealing Hospital, where there is much uncertainty regarding the future of various specialist services in view of the proposed merger with Northwick Park and North West London hospitals. Daily, I walk past protestors on the way into the hospital, campaigning for the A&E department to remain open, and for the retention of specialist services at their local hospital.

On the face of things, it appears to be detrimental to shut local services, but this is not the case. If you were to have a serious heart attack, your best chances of surviving would be to get you to a catheterisation suite, where a specialist heart doctor could inject dye and map your arteries, re-inflate areas of blockage with a balloon, and probably stent the arteries in order to ensure continuing blood flow. To be effective, this needs to ideally happen within 90 minutes of you first experiencing symptoms. This has many barriers, not least the amount of time it takes the average person to realise that they may be having a heart attack. Logically, to the public, it seems rational that getting to an A&E 10 minutes away will improve your survival rather than travelling an extra 15 minutes down the road. 

However, the precision and speed at which these services are deployed increase with every person treated. If you are blue lighted to the Harefield, a specialist cardiac hospital, then they will have seen hundreds of thousands of the exact same case, everyone will have a preordained role and, on average, they can get you from ambulance to catheterisation in 30 minutes; assessment, examination, and diagnosis all happen on the move to the theatre. 

Now take Ealing. Admission to A&E, running an ECG, taking confirmatory blood test and diagnosing a heart attack will inevitably take around an hour. We just don’t have the specialist set up. Additionally, Ealing doesn’t do out of hours catheterisation, so most people will sit overnight awaiting operation in the morning. Somehow, the extra 15 minutes doesn’t seem so bad. The cardiac team at Ealing are exceptional, they are perhaps the best functioning team in the hospital, however, there is only so much you can conceivably do in a district hospital, and there just aren’t the facilities for specialist treatment.

Specialisation of services is not a bad thing. Yes, it is incredibly frustrating for the cancer patients who have to attend multiple hospitals for treatment – radiotherapy at one, surgery at another, follow up at their local hospital. Yes, it is a pain in the ass travelling continually for medical treatment. But if the alternative to that is sub par medical care, I think I would do the travelling. 

Aneurin Bevan is my hero

The NHS gets a bad press. 

As an organisation founded in 1948, it is no wonder that it is struggling to keep up with the growing demands and expectations of an ageing population. The fundamental principle of a free at point of service healthcare system for all, is something that I am immensely proud to be a part of. It is consistently portrayed as a decaying and inefficient system, with no option other than privatisation viable to sustain it. 

I think this is a mistake. 

I have first hand experience of the dedication of NHS staff to ensuring effective and timely management for patients regardless of their social status. With privatisation will inevitably come prioritisation, and we will be in severe danger of losing the ethos of our healthcare system.

Despite the overarching belief that the NHS is an outdated model which needs renovation, England still has the best healthcare system in the world. I think it is pretty spectacular that from first presentation at A&E to diagnosis and initial management of complex diseases such as cancer and heart failure takes on average only 48 hours. And 4 of those will be spent waiting in A&E…

My colleagues and I consistently stay beyond our finishing time in order to update families about patients’ progress, or to deal with emergencies that inevitably seem to occur at 5:30 when you are crabby and tired after a long day and should have left the hospital already. There is a sense of shared responsibility, a sense of duty and an underlying pride at being able to provide the world’s best medical input for people who would be otherwise unable to afford it. Yes, there are days when the inefficiency stifles me, when I get irreparably frustrated with our lack of resources and the dissatisfaction of patients and staff alike, but on these days I try to take a step back and remember the principles that our system is based on, and the ethos we are working for, and then the shortcomings don’t seem to matter as much.

The NHS has become a political model, and as such it is not left alone long enough to gain level footing. Every new government has to have a different plan for saving the NHS, and as such none of them are given time to work. Instead of giving up on it, we need to accept that as an organisation it is always going to require more funding, it is always going to be inefficient (because how can you legitimately price health?)..instead of lamenting this, we should be proud of it. There are few better things to spend our money on than health provision. We should be praising NHS staff, and supporting them, bankrolling them, celebrating them. We still have a reason to be proud of our healthcare system. We should not condemn it just yet.