A couple of weeks ago, I encountered an interesting case referred by my medical colleagues for review. The patient initially presented to a private hospital for fainting spells. He was seen by the cardiology service and was subsequently referred to a government funded hospital because of financial constraint.
The on-call physician saw the case at 4pm and wrote in the notes: For urgent cardio referral cm.
The 'coming morning' was in fact on a Saturday. My medical officer received this referral early in the morning and narrated the case to me. We went to see the patient together and I must say, I was amazed at the subtle signs of uncertainty displayed by my medical colleagues.
The patient was diagnosed as having non-ischaemic dilated cardiomyopathy with an EF of 20%. The private cardiologist's assessment was that this patient might have recurrent ventricular tachyarrhythmia hence causing recurrent syncopes. They did an MRI to rule out an intracranial pathology. The MRI showed an incidental benign cyst which could not have accounted for the symptoms. But because of the 'obvious' finding on brain MR, the patient was 'siphoned' to the neurology service.
The physician in-charge of the neurology ward was almost certain that the incidental benign cyst would not have accounted for a more serious problem. On the other hand, it was quite clear that she hesitated on the 'urgency' of referral to the cardiology.
It was half past four in the afternoon, I must admit that it is a 'semi-taboo' to make non-urgent referrals at these hours. People are packing up, preparing to take rest after a long day work. Any non-urgent referrals at this time are pretty much unwelcomed.
Nevertheless, URGENT referrals must be made instantly, regardless of the time of the day!
The very fact that she chose to write: Urgent referral coming morning, simply reflected the uncertainty of urgency in that sense.
Well, to me it's simple. We all will become uncertain when confronted with problems out of our specialties. The solution is simple. We walk to the nearest phone, pick up the dialer and ring up the specialty in regards. One call would clear out the uncertainty.
Unless, of course, ego and pride set in to hinder that walking up to the phone, picking up the dialer and engaging in a consultation.
Unfortunately it happens all too often in the service, sad to say.
The on-call physician saw the case at 4pm and wrote in the notes: For urgent cardio referral cm.
The 'coming morning' was in fact on a Saturday. My medical officer received this referral early in the morning and narrated the case to me. We went to see the patient together and I must say, I was amazed at the subtle signs of uncertainty displayed by my medical colleagues.
The patient was diagnosed as having non-ischaemic dilated cardiomyopathy with an EF of 20%. The private cardiologist's assessment was that this patient might have recurrent ventricular tachyarrhythmia hence causing recurrent syncopes. They did an MRI to rule out an intracranial pathology. The MRI showed an incidental benign cyst which could not have accounted for the symptoms. But because of the 'obvious' finding on brain MR, the patient was 'siphoned' to the neurology service.
The physician in-charge of the neurology ward was almost certain that the incidental benign cyst would not have accounted for a more serious problem. On the other hand, it was quite clear that she hesitated on the 'urgency' of referral to the cardiology.
It was half past four in the afternoon, I must admit that it is a 'semi-taboo' to make non-urgent referrals at these hours. People are packing up, preparing to take rest after a long day work. Any non-urgent referrals at this time are pretty much unwelcomed.
Nevertheless, URGENT referrals must be made instantly, regardless of the time of the day!
The very fact that she chose to write: Urgent referral coming morning, simply reflected the uncertainty of urgency in that sense.
Well, to me it's simple. We all will become uncertain when confronted with problems out of our specialties. The solution is simple. We walk to the nearest phone, pick up the dialer and ring up the specialty in regards. One call would clear out the uncertainty.
Unless, of course, ego and pride set in to hinder that walking up to the phone, picking up the dialer and engaging in a consultation.
Unfortunately it happens all too often in the service, sad to say.
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2 comments:
I guess, physician is a physician, sometimes one might want to adopt a "wait-and-see" attitude. As a physician, one cannot be 100% sure that the so-called benign cyst would not be the cause of the patient's symptom. As long as the patient is asymptomatic and the ECG was normal at that time, I guess it is still fair to observe the patient overnight, and especially so, since it was near off-duty as you mentioned, unless the patient has a life-threatening condition. Since the patient was in her 'house', I guess she probably didn't want to cause embarrassment just in case it could be a neurological condition? Sometimes, it may be easier said than done, would your expectation still the same, if the patient was admiited to the cardiology ward first?
Hi dear eColi,
Glad to see your post after such a long time :)
Yes i totally agree. The doctor in regards was not sure whether it should be an urgent referral or otherwise. It was very clear in the train of thoughts as outlined.
In retrospect, we found out that the doctor was not exposed to cardiology posting at all in the training. Well, he/she had refused to be admitted to cardiology posting i should say.
Well that's not the major issue here. I do agree that we all WILL HAVE doubts on the issues out of our specialties. Setting this fact in our mind, we must do away our pride and ego and engage READILY in consultation with 'friends' from their respective specialties.
Passing the 'buck' to the doctor in the coming morning to do the job is not the best thing to do, to say the least.
And finally to answer your question, how would be my expectation if the patient was initially admitted into the cardiology service? I would walk to the phone, pick up the ringer and call my neurology friend and make a 'informal short' consultation, telling them my plan and obtaining their feedback at the same time. Not a very bombastic job to do and definitely should be the trend in medicine. Don't you agree?
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