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!