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Monday, September 19, 2011

Conundrum of Consultation.

Few years ago a fellow physician asked me to see a patient. When I asked him why he said “STP”,  he chuckled and said “for STP, share the pain”.

As a hospitalist, medical consultation is one of the essential components of our work. Various specialists require assistance in areas which are beyond the scope of their expertise. So, an orthopedist may want a hospitalist to manage infections or diabetes or a cardiologist wants us to evaluate a patient for abdominal pain. The reasons could vary. Some are from orthopedist, some from cardiologist etc….. 
They vary from atypical chest pain to coagulopathy. Most of them are very appropriate and we love to tackle medical problems of all sorts. But then there are some consults which are called for all the wrong reasons.

Interestingly when you look at the reason for consult, mostly it is a very vague reason like “medical co- management”. However, at times when you ask the nurse the reason is entirely different.

Don’t take me wrong, most of the times physicians need assistance like if someone is septic, they want a hospitalist or intensivist to take over the case. If someone has brittle diabetes, they want an opinion for better glycemic control. But some times the consult could be just STP (share the pain) or just indifference. At times  referring physician just want someone else to do their scud work. 
However, regardless of nature of the consult you would almost always find this statement at the end of dictation “Thank you for allowing me to assist you in this very "interesting patient”"

I will give you some very “interesting” consults I have received in the past few years.

-      A nurse called me for a consult for “medical co management”. I asked her what the story is? Apparently patient was very belligerent towards the attending physician. After the attending physician left patient wanted to leave against medical advice.  Nurse called the attending physician; he did not want to be bothered. When she asked for further direction, he said lets call for a hospitalist consult. That left me very perplexed. What am I suppose to do, get a couch, asks the patient to lie down and provide behavioral counseling?

-        I was called for diabetes management on a chest pain patient. When I came down to evaluate the patient I found out she was a 91 year old lady with hospice for terminal lung cancer. Apparently EMS brought her to the hospital while they were on their way to hospice house from nursing home. In the ambulance she started to moan. EMS thought it was a good idea to stop at the hospital. ER physician decided to admit this hospice patient.  On the whole scheme of things diabetes was the least of her problem. I spoke with the family and transferred her back to hospice.

-        Sometimes the consult is called because the surgeon or a refereeing physician does not want to perform medication reconciliation or discharge paperwork; we are consulted for “hypertension”, when patient is on a hint of diuretics for hypertension. They just don’t feel like doing it I guess.

Now on the other hand I would rather be a consultant on some cases than being the primary attending. Few years ago I was called to admit a 42 year old man with chest pain due to a thoracic aortic dissection. After ER physician finished presenting the case I asked him “do you think I have some divine connections, if you want I can come down and pray for this patient at bedside, as I am surely not a cardiothoracic surgeon and you want someone who can crack open his chest”.

Sometimes when I am being consulted I feel transiently important, it is good for my ego that they want my opinion. On the other hand I think we need to have very clear and defined reason for consult, not just “co- management”. This would not only improve care but also clearly focus on the specific issues which need to be addressed. Like the other day I saw a patient for “co-management”. Later found out that the physician was concerned about the side effects of a certain medication. I missed it completely as this was not mentioned nor conveyed to me at any time.

I can see how we need to improve communication from our side. This is an ongoing project at this time.

PS: About the picture: This is not a magic ball. Inside Vatican Museum.

1 comment:

lovingheartpatientadvocacy said...

Human Factor, I like your blog very much. As a doctoral student of Medical Humanities Medical Humanities (which deals with the intersection of the human experience, medical practice, and scientific technology), I really appreciate you interest in mixing medicine with the very personal experience you share with your patients.