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Who Wins?

Who Wins?

I remember a time when things were simpler than today. People used land line telephones to communicate, there were three or four channels on their television sets, and our most cherished moment was receiving a personal letter from a loved one in the US Post. People cared about community, had pride in their cities and towns and they believed in assimilating into American culture. Today we live in a world of too many choices.

Several weeks ago, I evaluated a patient that had a number of signs and symptoms that seemed to emanate from one illness. At least that is what she thought. Several prominent characteristics of her illness were extreme fatigue, chest pain, joint aches, stomach pain with bouts of constipation and diarrhea, pain on urination and vertigo. As you well might expect she had a cadre of specialists guiding her care: a cardiologist, rheumatologist, gastroenterologist, an internist, a gynecologist, a urologist, a otolaryngologist and a general practitioner. None of these physicians cared what the other thought. No one physician had the patient's best interest in mind. The patient suffered every day, but continued to seek medical advice from anyone who would listen.

Thirty plus years ago, when I was in medical school, specialists were considered consultants. And they wanted to stay that way. They spent extra years in fellowship training studying rare illnesses primarily related to a physiologic system. A pulmonologist would study diseases that are related to the lungs, a cardiologist would focus on heart disease. Although each specialist typically passed the internal medicine qualification exam, once their training was completed in their specialty, they desired only to provide information to the primary care physician about their referral as to the state of the art care for the disease or syndrome related to their field of higher qualification.

I remember vividly conversing with a pulmonologist who was angry at a primary care physician who continued to refer simple asthma cases to him. He did not want to treat simple asthma, his desire was to educate the primary care physicians on how to treat simple asthma, and then move on to the next complicated lung disease. He was disease oriented, not patient oriented. This particular primary care physician saw his role as an air traffic controller, guiding patients to specialists and telling patients to follow the specialist's advice, regardless of the simplicity of their disease.

Sending patients to multiple specialists with different world views carries a significant risk, the patient has no true understanding of what to do and they become confused about which way to travel down the therapeutic path. This particular pulmonologist called up the primary care physician and told him to brush up on his asthma knowledge and only send him the most complicated asthma cases. That conversation was difficult to listen to, but it made a mark on my understanding about fragmented healthcare.

When I finish my clinical pharmacology and medical toxicology training, I started to see the world from a specialist's eyes. There was a time that I had hospital privileges in every hospital in the Memphis area. I was consulted on every drug overdose, intentional or not, every adverse drug reaction, every possible poisoning case, every liver transplant case that had no clear reason for liver failure, every snake bite, every spider bite and any patient in which the differential diagnosis could include a toxic reaction to something. My world view became skewed. I thought every disease was a result of a toxin of some kind. I was always on the go. Never stopping to catch my breath or read about illness in the greater sense of the term. Although I tried to educate physicians on the care of patient's manifesting some form xenobiotic toxicity, most of my words of advice fell on deaf ears. It was much easier for physicians to refer and defer care to me related to poisoning than actually expanding their own knowledge and expertise.

One morning, I went to an ICU at one of the Memphis area hospitals to evaluate a young woman who had allegedly overdosed on phenobarbital. When I got to the ICU, I found the floor void of any nursing personnel. Ventilator alarms were going off and IV monitors were ringing, but no one was there to check on the problems. I found all the nurses in the break room having a party. When I went bedside, I saw a patient on an intravenous drip of Propofol as well as a ventilator. She was in coma, a physician induced Propofol coma, not a self induced phenobarbital overdose coma. When I read the chart, the young woman was alert and talking in the emergency room, but she was uncooperative. She had taken a handful of 10mg phenobarbital tablets because she was upset at her boyfriend. She did not agree to have her stomach pumped, so the emergency room doctor decided to chemically restrain her, and lavage her stomach. He decided to put a breathing tube into her trachea to keep her from aspirating material into her lungs. Hence he started a Propofol infusion to keep her sedate and cooperative.

Once the emergency physician performed the procedure, he decided to keep her on the ventilator and ship her to the ICU. He felt he did his job on the front line and passed her on to the doctor on call. The doctor on call consulted me to help her successfully wean the woman from the ventilator. I was essentially consulted to clean up the mess. After I assessed the situation, I realized that the girl was never in danger from ingesting the phenobarbital. She had taken the medication since she was a child and was very tolerant of changes in her blood levels. When I looked at her chest X-ray, I saw that she had developed aspiration pneumonia from the aggressive lavage procedure the emergency room doctor performed. Charcoal was coming out of her endotracheal tube.

I called the emergency room doctor. He was still on shift in the emergency room. I questioned him about his clinical judgment in this case. He gave me a litany of answers, all logical but profoundly irrational. It became clear that his intention was to punish the girl for overdosing and seeking medical attention at the emergency room. He made the comment, "I had to teach her a lesson. I don't think she'll do that again anytime soon."

When I hung up the phone, I spoke to the on call physician who admitted the patient. We started the patient on antibiotics for aspiration pneumonia, weaned her from the Propofol infusion and got her off the ventilator within twenty-four hours. The patient went home feeling sad and coughing up charcoal. I went to the medical staff office and complained about her care in the emergency room. The only answer I got was, "No Harm, No Foul." I resigned from the Medical Staff that day. I was tired of fixing everyone's missteps and seeing patient's in the hospital who had been abused by the system. Most of the patients I consulted on were ill as a result of physician ignorance, not patient non-compliance or disease progression. Compassion had departed from the medical field and I was being used to cover up plenty of untoward iatrogenic disturbances.

So what does that story have to do with anything? Plenty. In the old days of medicine, specialists were consulted for their opinions about the clinical care of a patient. It was a consult. Whatever information was relayed, it was up to the primary care physician to integrate the medical advice into the whole of treatment. Sometimes it required a phone call to the consultant to discuss other treatment options if the patient couldn't tolerate Plan A. Now, specialists routinely manage the aspect of a patient's disease complex that the specialist believes to be under their expertise, seldom taking into account any other aspect of the patient's illness that might generate a flaw in their medical decision making or prescriptive habit.

The patient who was described at the top of the page is about ninety-percent better. She was on ten medications, now down to two. She cleaned up her diet, lost forty pounds and exercises frequently throughout the week. A careful history revealed that she started having problems with her health after seeing a number of specialists who treated her for minor symptoms and blood cholesterol elevation. Her medications created a number of side effects that generate more medications and misery. Although I tried to speak to some of her physicians about changing her therapy, I could only reach their nurses who related that their doctors would call me if they had issues with my care; so far, no word.

I naively thought that personal computers, internet access and medical decision making would improve the care of patients because the time saved in paperwork would allow physicians to spend more time with their patients. Instead, it has allowed them to overbook, spend less time with people and create standard algorithms and protocols to practice by. Primary care physicians are the Gate Keepers of the system in general and have no real command of the patients they treat; they just refer and defer care. 

I do not have any sound predictions of the healthcare to come in the future. I think one day there will be a battle between the solo practitioner who wants to deliver the best care for the best price and the corporate practice model which wants four referrals to specialists for every patient complaint to cover their bases, whatever that means. It seems like the book, American Gods. A clash between the old way and the new.

Who wins? The innocent patient beneath their feet suffers while the battle rages on.

Doc

Posted by Amanda Sanders at 11:13 AM
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