Hey I Know Someone!

Today, I had an aquaintance with Mr Q, which is a local mobile phone dealer with an attitude. He has a grandma who was admitted with a diagnosis of chronic AF with overwarfarinisation. Her INR on admission was 3.8 - which is slightly above the recommended upper limit of 3.5.

She presented with haematuria of 1-week duration. She also feels tired and has lost weight and appetite. Upon further questioning, it was clear that her active problem was the least of a primary cardiac one. She has been diagnosed to have carcinoma of cervix and she had been under the surgical colleagues for an episode of intestinal obstruction. I gather that the staging of her carcinoma would at least be II or III depending on the local tissue infiltration. I hence told him that I would call upon the help of my gynaecologist colleagues to give their expert opinion. At the same time, I explained to him that my department would continue to monitor his grandma but there would be no active management on our side.

He was puzzled and asked me why would his grandma been admitted into my ward instead of gynaecology ward. Before I could react, he proceeded to demand that my department be held responsible for everything and that he would not tolerate any delay in treatment of her grandma. He also threatened to bring this matter up to the hospital director AND to the local politician, as he claimed to know someone 'important' in the state Excos.

I smiled and tried to explain.

I reiterated that the doctors and supporting staffs here were all-out to help her grandma to recover, nonetheless, the expertise in treating the underlying primary disorder, unfortunately was not our specialty, and hence a referral and consult with the gynaecologists would be mandatory as part of the holistic care.

After much explaining and exchange in words, finally he settled down and accepted my terms.

I curiously asked: 'Who's the local politician or state Exco that you know?'

He hesitated for a moment and blurted: 'Actually I just happened to have sold a handphone to him and got his name card. I don't know him that close lah.'

Moral of the story: Claiming to know 'someone' to get 'something' done is a rather common phenomenon the local setting. Doing favours and returning favours are part of Asian culture for centuries. Nevertheless, at times, it could be quite condescending and to a larger extent, unethical, if the favour is done at the sacrifice of other patients interest, especially so in the public healthcare system.

The Odds of Uncertainty

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.

Hidden Agenda

Very often, we're faced with patients and relatives not telling the truth in the first instance. The reasons are plentiful. Some of them might need more time to develop trust. Some might simply prefer not to tell the truth. Some will not like that particular doctor for no apparent reason, and will promptly tell everything to another. For some, there are hidden agenda..

Well, I must say, the word 'hidden agenda' is sort of a magic word for us the Membership holders. We're forced to adopt the thinking that hidden agenda are there to stay for every Ethics & Communication Skills cases. Hidden agenda is hidden concern by the patients or relatives in regards, which serves to be the key to open up opportunities for further discussion or sometimes, it might well be the prerequisite for task accomplishment.

Allow me to share an atypical 'hidden agenda' incidence which was experienced by one of my colleagues days ago.

A young lady was admitted for allegedly ingested detergent liquid for parasuicidal attempt. She was otherwise well apart from some epigastric discomfort. A lavage and all other proper management measures had already been undertaken. My colleague needed to move on to see the rest of the wards before moving on to run the clinic.

As an MRCPian with extensive 'awareness' on the issue of hidden agenda, my colleague of course had elicited the very reason behind her parasuicidal attempt, ie, she found out that her husband was having an affair (Of course, this is after some repeated questioning, not volunteered). Her relatives were practically encircling her with intense concern, asking repeatedly about her conditions. My colleague practically failed to carry out his ward rounds, in the presence of so many visitors. Worse still, the relatives at one point were trying to suggest that NO EFFECTIVE treatment had been given, and threatened to take this matter to a complaint.

Nothing happened eventually. But an interesting point to illustrate here.

The patient committed suicide because of his act of seeing another women. You brought her looking for help and treatment. We gave help and treatment. You still have guilt (logically, he should). The patient refused to talk to him. He sensed a even stronger share of guilt and wanted a way out. The way out is simple - repeatedly showed concern by questioning the medical staffs, even to a point of irrelevance. And if they refused to hear anymore, it's their fault! Not my guilt anymore! How about the care of other patients? Don't care, not my problem!

This might be a over-simplified attempted deciphering of his thoughts. Nonetheless, one should recognise that some patients or relatives are just inherently selfish. It's their nature. Especially so, at the very juncture of escaping from guilt.

To Ministry With Love

Of late, I have reason to believe that this blog has been perused by the Ministry people. A close friend of mine had told me. To be honest, I am very pleased by this fact, as one of my intention of writing this blog is to get some attention from the ruling party ie the Ministry policy makers.

I told my friend that the primary aim of this blog is indeed to tell the relevant people the various interesting events happening in a hospital, whether too smart or too lame..

More importantly, I was also 'warned' not to write on issues criticizing the system again. Frankly, I wasn't surprised at all. This system has always been one with people yelling high speeches of democracy, freedom and human rights on the outside, but in reality, a lot of things we are expected to keep quiet and cease public discussions.

The people in support of this would say that it's for the greater good. Hmm.. sounds familiar isn't it, and how about some addition of words to the sentence that goes like this: 'For the greater good so that we could maintain the state of peace, harmony and prosperity!'

Sweet deal and a real music to the ears! While I am totally a peaceful person, nonetheless, I think keeping quiet all the time and taking no heed on the reality is not something that we should be endorsing in the long run.

I think the Ministry is able to do better than this. Some helpful voices from the inside and some sincere comments from the outside would be good.

I have come across very high-ranking officers in the Ministry who is much willing to accept critics and views. If one who is at a higher post is willing to accept, why shouldn't his subordinates?

That is absolutely a useless attribute to hum and sing 'I wanna know the truth' day in and day out, but in reality stays contented with a world full of lies and illusions. Someone is already on the verge of getting his final paycheck. Would you be the next?

A New Wave Of Change

The recent nationwide general election results took us by a surprise. Nothing medical here. At least not directly related. But I must admit that everything and anything is essentially connected, in some ways, to politics in this modern civilisation.

Rather often, we clinicians do find ourselves in a tight spot to fulfill some special 'uninvited' demands from the local politicians. Some might not be the politicians themselves, but they were their friends, neighbours, relatives etc.

Queue-jumping, requests for early consultation, early appointments, special attention, demand for the 'best' medicine available... these were invariably some but not all the things that were happening over the years that I've been serving in the ministry.

Worst still, when I was serving in one of the smaller district hospital years ago, I was repeatedly confronted by outpatients who claimed to be the close friends or neighbours of our Prime Minister!

"Best medicine for me, I'm his close friend." This statement was utterly too familiar to hear.

"Don't worry sir, I am already giving you the best." Admittedly, not much of a choice, I need to use a rather 'political' statement as well. Interesting, isn't it?

I do hope that this new wave of change be served as a humble awakening to all, not just the local politicians, but also the people who endorsed them.

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?