Friday Reflection 41: Sometimes I Just Need to Complain

A 76-year-old woman presents to a community hospital after waking with garbled speech and right-sided weakness. She is admitted with suspected stroke.

I love my job. If I had it all to do again, there is no doubt that I would choose medicine in general and academic general internal medicine in particular, but occasionally we all have a bad week. Last week was one of them.

There were no personal crises or untoward patient outcomes. What there was -- courtesy of colleagues from across the country – were cases illustrating needless excess, careless follow-up, poor commitment to clinical care, and the devaluation of primary care that undermines our entire system.

I know that listening to people complain can be pretty boring. I hope that the medicine and the larger message here will make this seem like more than the whining of a privileged old man.

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Case 1: Excess

An elderly woman is admitted to a community hospital with a minor stroke. The hospital does an excellent job. She has the appropriate imaging (brain and major vessels), lab work, and echocardiogram. By the time she leaves the hospital, she has no residual symptoms. She is discharged on dual-antiplatelet agents and an increased statin dose. She follows up at a “highly ranked” west coast academic medical center, near where she lives half the year. The plan was that she would get a two-week, continuous EKG monitor placed and have a sleep study at this hospital.¹

What did the medical center do? They did the Zio patch and sleep study. They also repeated all the tests that the community hospital had done. And then, I guess because cancer-related hypercoagulability could conceivably cause a stroke, they went further. Even though the patient was already up to date on age-appropriate cancer screening (cervical, colon, and breast) and was perfectly well, with no symptoms, the medical center doctors completed an upper endoscopy with ultrasound (EUS), MRCP, and genetic testing. For good measure, they also implanted a permanent, subcutaneous, cardiac monitor.

Fortunately, healthcare is free, and the patient was not harmed by the testing.

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Case 2: Carelessness (with some hyper-specialization and disrespect thrown in)

Six months ago, I referred a patient to a specialist for a biopsy. The initial pathology was inconclusive, so further genetic testing was done on the sample. Results were returned a couple of weeks after the procedure and went to the specialist, the doctor responsible for follow-up. I recently saw the patient, and upon reviewing the chart, noted that the genetics suggested high risk for malignancy. I referred the patient for a definitive procedure.

I called the specialist to let him/her know what had happened and how I was proceeding. The doctor was distressed at having missed the results of the tests. Two comments during our conversation stood out.

“Well, this isn’t really the aspect of my specialty that I specialize in.”

“I’m glad you picked up on the results, primary care doctors often miss things like this.”²

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Case 3: Lack of commitment

This one barely registers as it happens so often that I just accept it as my lot in (professional) life. A patient sees another doctor for a visit, a procedure, or surgery. In the days following, there are questions, or test results, or complications. I get the call from the patient because they can reach me but cannot reach the other doctor.

I relish being called upon by one of my patients after she has seen another doctor. Usually, these calls are to help her better understand a complex medical issue or review recommendations, incorporating her full medical picture and values. This is my job as a generalist and a primary care doctor. What I do not relish is being called in desperation by patients who cannot reach the doctor responsible for the issue at hand. My time is more than occupied with issues for which I am primarily responsible.

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Case 4: Lack of commitment

A patient of mine was seeing an outside surgical specialist who did not share our medical record system. He was managing one problem when an imaging test, which I had ordered for another reason, revealed a finding important for his management. I called him before my patient’s upcoming visit to update him. After seeing the patient, he told my patient that she should call me to thank me because “so few doctors would go above and beyond like that anymore.”

This only affected me because of the week I was having.

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Read this as you will -- an old curmudgeon cursing at the kids playing on his yard or a 750-word humble brag. I wrote it thinking of these as experiences that underscore what worries me about medicine today: overspecialization; a loss of focus on patient care; and a devaluing of primary care when patient needs are increasing.