January 31, 2008

Three Vignettes You Won't Understand Until I Explain Them, And Then It Will Be Too Late

Hint: what do the doctors not do?


I say, "Hi, Dr. X?  My name is Dr. T, from University Hospital, we have one of your patients here, Joe Blow, and he says he is on a very large dose of phenobarbital, so I'm trying to verify his doses and his seizure history."

"I know Joe, and his phenobarb does is 500mg per day with Dilantin 500 per day.  He has intractable seizures from several head traumas about ten years ago.  Other than that, he has no other medical issues."

"Wow.  Well, thanks for your help."

"No problem.  Bye."




"Hello, Dr. Alone, this is Dr. Ted, calling you back about John Smith.  According to the chart, I last gave him a prescription on 11/17, and at that time I gave him HCTZ 25mg #30, Percocet #60, and Prevacid 20mg.  If you need any more information, you can call me back at the same number.  Thanks."

end of new messages



The medical student hangs up the phone.  "That was fast," I say.

She nods.  "I told him I was a medical student at University Hospital, and that we were trying to verify his medical history, but Dr. Block said he didn't remember Mr. Robinson so he said he'd have to have the nurse call me back to read the chart."

"Oh," I say.


What these stories have in common is this: the outpatient doctor did not bother to ask why his patient was in the hospital.

That's universal healthcare; or at least Medicaid and Medicare.  Some doctors know everything about their patient, others know almost nothing, there's a variance but what's becoming more common is an apathy and disinterest in the maintenance care, the "across the life cycle" total patient care.

They figure: he's in the hospital, so presumably he'll be managed.  I don't have time for this, I'm busy, I have-- well, patients to see. 

The outpatient doctor isn't a "gatekeeper," he is simply a member of a large, disconnected team of clinicians who each care for a different medical and temporal aspect of his life. We are all consultants now.  Contact between clinicians is usually about the past-- what did you have him on?--- or the short term future-- when can he see you next?  It is almost never about the "total patient," integrating neuro with surgery, derm with endocrine...

The odd exception to this is psychiatry, but only private practice psychiatry.  Community mental health is still a type of temporal consultant: if he shows up, you treat him.

When was the last time you talked to the internist of a patient about why/how you're putting him on Zyprexa?

I'm not any better, I'm afraid.  The system isn't set up to care, it's set up so you care less-- because the less investment you have in being the gatekeeper, the more freedom everyone-- other clinicians who may bump into him down the line-- has in doing what they think is best.  I hardly need to point out that not only are we not paid for consulting with other docs, but we lose billable hours and introduce each other to higher liability because they're now on record as being privy to my crazy Depakote + Cytomel+ testosterone plan.  And no doc dares d/c the meds of another without good resaons-- good reasons that unfortunately no longer include "holy crap, that doctor is an idiot!"