The 'Take-over' Conundrum

I believe the talk of taking-over patients from the periphery establishments has been on for centuries ever since the decentralisation of the service.

I personally believe that there are 2 types of referral in our medical world, I would arbitrarily call them type 1 and type 2;)

1. Type 1 referrals - Referrals made on clear clinical grounds. Diagnosis is clear and the reason for referral is for the referred party to offer treatment modalities which are not available in the referring centre. Classic examples would be STEMI failed medical thrombolysis needing rescue PTCA, relapsed nephrotic syndrome needing renal biopsy, and acute subdural haematoma needing surgical evacuation.
2. Type 2 referrals - Diagnosis is not clear. Referral is basically made to seek for opinion on a higher level. No clear plan outlined by the referring party. The referred party is hence asked for a suggested plan of management.

I've always emphasised to anyone that both types referrals are indicated and would probably deserve some respectable attention from the referred party. Type 1 means you have a rightful duty to be carried out. Type 2 means one of your other colleagues is in trouble and hence need help. Help in our medical fraternity is so vital that no single medical personnel can operate effectively without some collaborative strategies.

But the question comes always is that: "Should we take over all type 2 referrals and hence embrace all responsibilities?"

Unfortunately, there's no simple answer to this. It is, rightfully so, of a case-by-case basis.

Let me illustrate this further by referring to a referral which I'd received just yesterday from a district hospital.

A senior medical officer had called in to consult regarding the management of a patient with acute STEMI. After a long winded story, she in fact wanted me to take over this case to my hospital. I told her to thrombolyse on the spot as time was of the greatest concern in MI. She was reluctant as she had little experience in treating acute STEMI before. I was amazed by this very fact!

And then after much questioning and answer, I also found that she wasn't so sure about the diagnosis of MI! Patient hadn't got any chest pain. She admitted to me that she wasn't so good in looking at ECG! She told me that there was some funny changes in the ECG which could be an MI. She in fact was totally clueless of what's happening!!

I was speechless as to what I could offer to help. Obviously she probably needs to go back to medical school!!

This is somewhat I called a type 3 referral. Nothing fancy. Just an exaggerated form of type 2 if you like:(

Totally clueless, and hopefully you could dissect the case in the matter of minutes through phone conversation. Sorry, you don't have the luxury to examine the patient, let alone to take a history. Your diagnostic tool is just the strings of voices from the telephone!

Admin Veteran At Work!

Well, not surprisingly, I ran into some disputes with the admin people again after a while in district. Just like my days when I was in another district hospital. It seems pretty clear to me that the climate of false sense of superiority among the admins haven't changed a bit through the years. Rather disgusting I must say.

This admin doctor is one of the senior locals who chose not to specialise at all in anything. I guess she must have been quite contented with her senior status and true enough, her monthly pay at her current ranking in the ministry is no small business at all. Approaching a 5-figure number in the local currency. That's something that a lot of us (including the smarter ones) couldn't get in years to come!

This fella even left her husband with a congenital cardiac lesion at a pretty late stage before asking me to intervene! I quickly referred him for surgery and thank goodness the lesion was not irreversible even though he's at his 40's.

I thought we have a rather good relationship to start with but guess what...a worse package of repayment is kept in store for me!

An employer of a schizophrenic who had defaulted treatment called her to clarify the diagnosis. I was keeping the folder with me as I wanted to summarise the case for the department. To be frank, it was a rather challenging case as he had a good red-herring which could be deceptive even to the best A&E doctors!

One of my colleagues had referred him earlier on for pacemaker insertion for symptomatic bradycardia of 50/min! In retrospect, the 'syncope' was in fact due to the psychiatric manifestation (panic attack)! The recurrence of syncope in the face of functioning pacemaker made the diagnosis clear, and at the same time rendered the earlier assessment rubbish and resource-wasting. (The history of schizophrenia defaulted treatment was not elicited upon referral!).

The employer must have been a little bit harsh on her. She was panicky when she approached me for the folder. I said I would look for it and hand over to her by the same day. I reassure her not to worry too much.

She became quite agitated:"You know you shouldn't have take the folder out of hospital see. They ask..2 days already. Now angry to me...Want explanation you know" She said in a stammering tone and half-broken English.

Later I found the folder in the on call room and handed to her in the same afternoon. I even gave her a clear viewpoint of this case (knowing that it's quite clinically challenging). I thought the issue was over for me but then..

The next day, my HOD called me and told me that the hospital director had known about this and had complained to him.

I was rather amazed by this very fact! A few points to highlight here.

1. A stranger called up the hospital looking for a clarification of a diagnosis of another patient. This clearly violates the principle of confidentiality! We can't even be sure whether the person over the phone was in fact the person that he's claiming as! If you'd told him everything over the phone, then I must say you must go back to med school to learn the basics.
   
2. Obviously, when looking for clarification of diagnosis, the admin people would not be the best person to approach for. I wonder why this issue was not passed to any of the physicians in-charge (including me of course). Clinical questions should be answered by clinicians, and not administrators! Period!
3. I helped her to locate the folder which was in the on call room. Lodging a complaint towards me is a counterintuitive measure, even for a 10-year-old. Unless, of course, her mental status was worse than a 10-year-old (which is, sad to say, quite a common ailment manifestation amongst the admin people in the ministry!)
4. Lastly, I was quite disappointed that my HOD didn't even listen to my side of the story before telling me off. He thought that I gave him trouble by keeping the folder! I'd forgive him for one fact - that he might be a bit intimidated as he's employed under the ministry on a yearly contract basis. The plight of the contract doctors?
   

Too Much 'Service-only' Mentality

Recently I have been observing the behaviour of my junior colleagues in treating certain common medical disorders.

One of which is hyponatremia . Well, it seems pretty obvious that most of them have taken this seemingly common abnormality quite lightly. During my round, I often question the provisional cause for the abnormality. Usually without failure, the answer would be: "Oh, the sodium is low and we're investigating it." But the key question is the provisional diagnosis, not that whether the hyponatremia has been investigated or not. Further more, I was totally upset when I found that most patients had been in the ward for almost 3-4 days, and yet not a single clue in the case note about the provisional cause.

Without having the slightest clue of the provisional cause, almost all patients would receive what I call the 'knee-jerk reflex' treatment of iv normal saline! I've always emphasized that the treatment for hyponatremia is not normal saline! As a matter of fact, if it turns out to be SIADH, then you're actually worsening it!

Of late, I caught hold of a few patients being discharged with the sodium level of 125-128mmol/L. Without a diagnosis or provisional diagnosis! When I glanced at the diagnosis column, it was written as: "Hyponatremia for investigation". No further plan pertaining to hyponatremia had been written. Some of them were even discharged to peripheral clinic, without a diagnosis.

Reasonably, these patients of course will present again for recurrent admission, pretty much due to the persisting disturbing symptoms of hyponatremia!

A few of my colleagues had a protective argument towards this phenomenon. One of which is quite classical.

"Well, we can't just keep patients too long in the ward. We need to discharge those 'stable' patients or patients with abnormality which can be investigated as outpatient."

I must say, I totally agree with this statement. But with a pinch of 'extra' salt. Suffice to say, we are in fact being overwhelmed by patients most of the time.

Excuse me though, I don't think hyponatremic patients with a sodium of 125mmol/L are considered stable. Furthermore, I think we should at least have a clue about the provisional cause for the low sodium and a clear plan of investigations outlined for future colleagues to follow.

Not discharging patients without a clue and expect somebody else to work out the cause for you, and in the meantime just pray hard that those hyponatremics won't come back again during your on call days!

This is what I strongly perceive as "service-only" mentality. Patients get admitted. Stayed for a few days. Some bloods were drawn. Cause of abnormality not sure. No provisional diagnosis. Not a clue. And yes, time to discharge the patient as we have more patients coming in. Must service other patients already. No time for 'academic' search for the cause. As long as it's not immediately life-threatening - discharge!

Finally, some of the patients in fact had very obvious causes. If only you care to ask. Some might not even need fancy diagnostic work-up. Just the plain old bedside tool of taking a good history!

The 'Clinical' Implication Of General Election

Last few days ago, our hospital has been in the hot seat for most local newspapers. The reason being, the husband of a deceased patient went on to the local politician and started whining his version of story. I had reliable information from my resident officers saying that their family (with the in-laws) had been in a state of discordance. And the act of going on to make a public complain might be a manifestation of that discordance.

To be honest, I don't really know if that's true. But one thing for sure, the local politicians sure gonna love this to the max, much for their own publicity.

Well, that's the typical local political climate. Whenever election is near, the politicians will line up with a hope to appear more often in the headline of newspapers. Sometimes, things might be trivial, nonetheless, they would not hesitate to go to the extra mile for publicity.

I think most of the time, we doctors are in the hot seat of being easily victimised.

After all, doctors only form the minority of the votes. Pathetic?

Good Boss, Nice Boss

After some time in the district, I begin to appreciate that being a good boss is no small business. On the other hand though, being a nice boss is relatively easier, and less taxing.

It might be hard to define what's good and what's nice. Let's put things into some common perspective first.

A good boss is one that carries enough qualities that permit him to be efficient to his work and towards managing his subordinates. He might have pissed off some of his subordinates from time to time for the sake of betterment of the system. Overall, he would still be welcomed by most of his subordinates. The support might be variable, nonetheless the system improves.

A nice boss is one that carries enough tolerance to his subordinates that allows him to be championed by them. He might do very little to improve the system but the support that he gains might be tremendous. His subordinates like him a lot because he would say 'Ok' to all their demands.

I think in our country, most bosses tend to adapt to the crowd well. They would become nice bosses eventually. The system, on the other hand, would be static and remain status quo for a long time before an occasional good boss decide to change.

Any good bosses up for the job?!

'Nothing To Lose' Mentality

Back in a couple of days ago, my senior MA told me of an interesting and yet distressing event in our clinic.

A patient suddenly ran amok and got into an heated argument with my MA and nearly punched him in his face. When asked what was the precipitating events, rumours said that it was due to a misunderstanding of appointment time given. The patient wanted to be seen right away. It wouldn't happen, and hence the cascading mishaps.

Another contrasting incidence happened quite some time ago in my in-laws house. My sister-in-law had just come back from her follow-up visit to a gynaecologist from a local private hospital. She was in the state of very remarkable anger. When asked what was the problems, she told me that the doctor was extremely rude to her. Rumours said that it was due to the fact that my sister-in-law had misplaced some tablets that were prescribed, and she wasn't following exactly the prescription. The gynaecologist had scolded her right in her face.

"Well, you could have just complained to the hospital admin, if you think he's rude. That's your right. You're in a private facility. Customer's satisfaction is their prime concern, for business." I suggested this, intending to calm her down.

She thought for a moment.

"No, it's no good making an official complaint."

"Why is it so?" I was rather amused by what she said, frankly.

"I waited so long and I've paid so much to see him. I can't just complain. It's not worth it. You'd never know whether he would change the treatment... or something like that. As long as the medicine is still working, it's ok."

As much as I can gather, most probably she didn't even dare to wink her eyebrows too excessively in front of that private gynaecologist. Let alone to mention about punching someone in the face;)

Ladies and gentleman, boys and girls, as you can clearly see from these 2 extreme examples that I managed to recollect, the contrasting facts are just quite self-explanatory!

The first case was a patient who paid around 5 bucks to see a specialist. He was angry because of a long waiting time, and he ran amok without much hesitation.

The second case was a patient who paid around 200 bucks to see a specialist. She was angry too because of a long waiting time plus the fact that she was scolded for poor compliance. Nonetheless, she was careful not to show too much of her anger in front of the doctor. And definitely no running amok kind of behaviour!

In the first case, there is this deeply embedded 'nothing to lose' mentality. Probably what he thought was that he had nothing else to lose except the 5 bucks. He walked out of the clinic in giant steps and style.

In the second case, 200 bucks is "everything to lose", for most people.

It's rather sad to conclude this way. Amidst the striving effort of government health care staffs to provide free or near-free service, the signs of appreciation from the crowd are still generally lacking. There are some who would show appreciation, but most would take it for granted.

Suffice to say, cultivating and nurturing the 'nothing to lose' mentality amongst them is not a good strategy in a long run.

One must have something to lose, else he has nothing to protect, not even his own integrity.

5-star Downgrades To No-star!

I stayed over the weekend for a wedding function in one of the supposedly 5-star hotels in the capital.

What initially thought to be a pleasant stay soon turned out to be a mess. Firstly, upon checking in, I found that there's no towel provided in the room. I called for an urgent supply. That's not the 'best' part, I later came to know that my 'debris' could not be flushed away in the toilet. I flushed repeatedly but it seemed that the pipe system had been engaging a bit of strike against the hotel. I called again for a fix, also reminding them about my towels.

I waited for an hour. I finally decided to go out to get things done by myself. I met with one of the service boys in the elevator and managed to get a towel. Lucky me.

I called for the third time regarding my complaints, stressing on the 'floating' debris that was more distressing than any other things. They didn't come, not until the late midnight. They apologised, saying that the whole hotel was fully housed with guests and they just couldn't cope with the demands. I said I understand.

A 5-star hotel gets downgraded (at least, in terms of rapidity of service) to a lesser grade.

Not that the hotel management did it on purpose.

Nor did the guests actually purposely overloaded them with demands.

It's just the way of the service industry works.

As the number of guests/ customers increases, the ability of the system to cope with the demands would largely depend on its available resources.

The same principle applies for medical health service as well.

It's even more staggering true in the context of public health service in this country.

Near-zero charges and an ever mounting number of patients.

The public needs to learn the necessity and the art of 'waiting', for a free service, run by just a handful of sorely underpaid staffs, under a system which is imperfect in many ways.

Build A District Empire, I Must

Yet another interesting gesture by some of my district colleagues.

My soft-spoken SHO, Dr AR, has complained to me recently about an incidence that involved her and one of the relatively more senior SHO from another department.

My SHO was tearful after being 'reprimanded' heavily by the so-called senior colleague.

The details of the incidence was not known to me, as my SHO was reluctant to carry the agony of going through the details once more. But I gathered that she must have been 'made' to given in to the incidence after being taken under heavy fire for some time. She wanted to make the incidence as 'personal' and 'off the record'. As per her soft-spoken character, I respected her decision.

If not, by virtue of my usual character, I would have summoned the 'senior' SHO for a mutual discussion.

As I was continuing my round with another SHO of mine, she told me that it was definitely not the first time that the 'senior' SHO in regard had acted this way.

"If you think she's been unreasonable, why not fight back?" I asked.

"She's more senior and her bosses cover her very well. Their department is stronger."

I was pretty much amused and subtly surprised by her comments.

I had to admit that though. My department has been a place with rapid shuffling of manpower and staffs, especially of the higher ranking ones, such as the head of department. The SHO pool was rather stable in a sense. This is partly owing to the fact that most physicians posted to the district will tend not to stay too long. They would stay for a year or so, and then got transferred away for subspecialty training.

On the other hand, there are 'hardcore' specialists in other departments who would stay in the same hospital for a long long time, thus cultivating and nurturing their own 'district empire'. Not only then, their SHOs would tend to follow suit, thus rendering an environment which is 'not intentionally' hostile, but 'much potentially' condescending for the lesser ones.

Having said so, the culprits are made up of merely a handful of them. Nevertheless, a handful is sorely more than enough.

No! You Can't Follow-up Your Old Patients!

I am not sure since when this phenomenon has prevailed. I picked up this comment while I was sitting in a combined clinic (obstetrics and general medical clinic) in my hospital.

After becoming a physician, I was posted to a district hospital pretty much near the vicinity where I live. Considering myself lucky, I accepted the 'offer' quite happily.

It has always been my style that I'd like to review patients that I've seen earlier on, so that I can keep track of their clinical response to treatment and intervention. I have been doing this alright with no problem at all..until I met with this old lady obstetrician in my district hospital.

It was a fine day. I walked into the consultation room. Happily browsing through the folders that laid in front of me, I asked one of the nurses: "How many patients are there for us today?"

"Why?!" The old obstetrician raised her voice, even before the nurse managed to throw in an answer. For a moment, I thought she was not yelling at me. I ignored.

"Hey, why?!" She blurted again, much in a stiffer tone of voice. I had already start noticing some gestures from the nurse.

"Oh, I would like to know the progress of the patients that I've seen during the last visit."

"No, it is IMPOSSIBLE!" She dragged the word "impossible" as though as I would not understand the word if she hadn't done so.

I walked away, went into another room sitting with another obstetrician and start seeing patients. I asked the nurse in the room for a favour: "Could you please walk to the next room and look for the cases that I've jotted down 'to see me on TCA' and bring them to this room?"

The nurse went. Minutes later, she walked back with 2 folders.

I went according to the queue number and saw the 2 patients in turn.

I had a short discussion with the O&G head of department later regarding the incidence. He was more approachable and agreed on my move to review previously seen patients.

There are 2 points to highlight in this particular incidence:

1. Following-up patients with regards to their management and outcome is just like doing a small 'cohort study' whithin yourself. It not only benefits the patients, but also the clinician himself as it invariably sharpen their clinical acuity over time.
2. 'Chronic' specialists residing in the districts can become complacent with time as their decisions tend to become 'unquestionable' by more junior colleagues. This cultivates a sense of false superiority in them. I call it the pseudo-superiority complex, as it collapses easily upon careful scrutiny by more experienced consultants from tertiary centres. I hope, one day, she will be scrutinised.
   

"Wifi"able My Clinic Area

Today, I made some improvements to the 'techie' aspect of my hospital clinic. I installed a wireless router onto the medical outpatient clinic.

Finally, I can get my hands on the internet for any information needed, in realtime that is ;)

Hopefully, that should also fix my relatively 'not-so-often' blog posts. Hehe.

I Want My Warranty!

Recently, a patient with a history of MI saw me during a stress test visit. He completed stage III without any complication. I told him that he had made an excellent recovery nonetheless keeping in mind of life-long adherence to medications and life style modification. I extended to him that a coronary angiography might be an option if he becomes symptomatic and interventions of either surgical or percutaneous route would be needed.

I routinely explained to him regarding the small but significant risks of on-table MI, stroke and death during angiography. He backed off after my explanation. It was as expected. I reassured him that medical therapy is as good as invasive interventions in face of asymptomatic status. He accepted and left my clinic happily.

I thought I have managed to convince a patient, but then..

10 mins later, a man busted into my room. Claiming to be one of his cousins, he demanded me to explain to him again from scratch. He told me that he knew Dr Z and Dr B (2 consultants in the hospital) well, and they always went out for drinks together.

Fortunately, I didn't have any more patients left and hence patiently I re-explained everything to him, in the presence of that patient. I reinstated the need of intervention in the future if he becomes symptomatic and the risks involved. I also told him that I have already made an informed decision with the patient.

"How do you be sure that he's ok if you don't do an angiogram on him?"
"I want an angiogram to be done on him."
"You know, if anything happens to him, YOU ARE responsible you know!"

I practically felt like being threatened and/or blackmailed by him!

In my clinical experience, I find that sometimes patients or patient's relative demand 'warranty' after a course of treatment. Well, the fundamental problem is that, THERE IS ABSOLUTELY IMPOSSIBLE TO HAVE WARRANTY IN CLINICAL TREATMENT!

Really, off-hand I can't recall any clinicians that have ever given out a 'warranty' to patients before. Enlighten me if I'm wrong ;)

That cousin of him really served well in 'sabotaging' the good doctor-patient relationship that I've strived to establish. Maybe one day, he could finally understand this when he's out drinking with either Dr B or Dr Z?

On second thought, maybe not...

I Say Oyster...

This post is specially dedicated to my dear comrades in my hospital who strive so hard in the path of becoming an MRCPian.

They are all taking the February diet in UK. I wish them all the very best!

Traveling in UK is a bliss. I'd had no problem at all in moving around the metropolitan. I don't work for TfL but I must say that their oyster card concept has been a great advantage for budget travellers like me.

You have the options of buying a flat-rate card for 1/52 travel or pay as you go etc.

Remember, my dear friends, YOU ARE JUST ONE STEP AWAY FROM BECOMING AN MRCPIAN!