Tuesday, August 15, 2006

Space for Rent

My psychiatry rotation during my third year of medical school was pretty random. I was placed with an addiction specialist, who specialized in sexual addiction. As you can imagine, I heard some interesting conversations that month. I don't know how much of an understanding I gained of the psychiatric profession, but as I was not allowed to directly interview the patients myself, I had quite a bit of time to reflect on my own thoughts that month.

One of the things the doctor kept repeatedly saying to his patients was that they had to "let things go, and not let people rent space in your head for free." A lot of our patients would hang on to one sliver of time for years, and never be able to let one altercation or instant in time go.

Late last night, I was guilty of letting someone rent space in my head. I saw a teenager who kept having episodes of fainting and dizzyness over the past year. He kept describing a barrage of symptoms that didn't really seem to all fit together. After making sure that his heart and electrolytes were fine, I had to call in a consultant.

The resident finally came to see the patient two hours later. This patient had arrived in our department at about 7 pm and it was now midnight. Granted, while I was seeing other patients, the resident spent at least a half-hour talking to the patient. Later, I saw him on the phone, and then he left. When I walked by my patient's room, I noticed that he was in his street clothes. He told me that the neurologist had said that he could go home.

I checked his chart: there was nothing written down.

I talked to his nurse: she said that she hadn't been told anything about the plan for the patient.

It was now almost 1 am: I had the resident paged. I asked him what his recommendation was, and he said that his attending just wanted to send the patient home and have him follow-up with his regular doctor. I asked him if he'd written a note in the patient's chart. He said no, that he had dictated his note. I said I needed some sort of documentation in the chart that he had seen the patient and what the recommendation was, as his dictation would not be transcribed or visible in the computer for several days.

He told me it has never been an issue before, and then demanded to talk to my attending.

I told my attending what had happened, and he just kind of said, "This has been a problem with consultants since I got here in 1993." I asked him to back me up, and explain to the resident that if he doesn't write a note in the chart, or at least speak with me about the patient, I have no way of knowing what the recommendation is. Fortunately, my attending backed me up.

I ended up staying until after 3:30 am (my shift ended at 2:00) catching up on my own dictations and preparing a case for conference on Wednesday. About 3 am, I saw the resident slink into the department and write a note. He didn't bother to talk to me, which is fine. I was still pissed off when I got home, and am still a little annoyed today.

I can handle being criticized by other departments when they don't like our workups or don't think that they are being appropriately consulted. However, when they do finally get their special-selves in to see the patient, I expect them to conduct themselves professionally. Most of them do write notes, and this is pretty much a resident-run hospital.

Somewhere, there is an attending physician that gets to bill for his opinion on this case that he discussed with his resident. If his opinion is important enough for him to bill for, or that I have sought it out, it needs to be documented. For them to not bother to even speak to us is not only rude, but potentially harmful to the patient. It is completely unprofessional and potentially dangerous for him to expect the patient to tell me what's going on. Even though I'm calling him for an opinion, unless that patient gets admitted, he/she is still in my care as long as they're in the department.

Hopefully, as I think this is a pediatric resident, I won't have to work with him all that often. However, I do want to find out more about what the official policy is on consults. One shouldn't be able to get payment for an opinion that you don't share with your colleague, and I certainly wouldn't have put up with this crap since 1993! I suppose it is a little unorthodox for an intern one-month into her residency to be calling out a senior resident, but seriously: do your job right, and I won't have to tell you how to do it. After four years of college, four more of medical school and whatever number of years in residency, one should have communication skills slightly better than your average chimpanzee.

On a happier note, yesterday I picked these up at the grocery store:

My ex-boyfriend was a huge Seinfeld fan, and he got me hooked on them. Some time ago, they stopped selling them in Arizona, so I was happy to see them here yesterday.

Also, I put seed into the bird feeder left behind by the sellers. It was then that I noticed the company name: Droll Yankees. Something about that just makes me happy.

For some reason, when I look at my blog, I can't see my last two entries. Is anyone else having this problem?


Chris said...

I was seeing the same entry issue on yours but when I clicked on your August 2006 entries it showed me all of them.

I LOVED your bit about dealing with the resident. The Crucial Confrontations series has a training session tailored to healthcare systems called "Silence Kills". I'll email you the link.


Sarah said...

Couldn't you get into trouble too? If you would have documented that you wanted a consult and then there was not a note in there from that Doc. (like if the note never got dictated) and something happened to the patient, couldn't he sue the hospital???? or....couldn't you get in trouble for sending him home if you didn't have proof???? I think now days you really have to CYA! :) Good job!

ru said...

It's hard to have respect for someone who disrespects others that way. Especially when it leaves you in a bad position and you have to spend time tracking down the response that should have been given to you in the first place.
I always like the phrase "heap burning coals on their head" or however it goes. I know it's talking about overloading the offending party with kindness, but it's much funnier to imagine the twerp with these flames shooting out of his head.
I hope that this guy is an anomaly and most doctors show more respect for their colleagues.
Completely unrelated: I am reading the bio of Upton Sinclair. Fascinating stuff.