Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Thursday, June 30, 2005

    Let me start off by saying, I could be completely wrong about this. Feel free to vote in the comments if you are so inclined.

    Last week I had a patient - young, healthy - who came to our after-hours clinic with a moderate cough that had been going on for about two weeks. No fever. The clinic doc prescribed an inhaler for bronchitis and recommended a chest X-ray. I called the patient next day to discuss. Frankly, because the clinic note and the patient's description of the symptoms sounded so mild I could have flipped a coin, but since the patient had not improved on the treatment suggested by the clinic doc I ordered the chest X-ray. Next day I was called by the radiologist, very excited, who reported a cavitating lesion in the upper lobe of the right lung. The radiologist thought it was TB. Naturally, I informed the patient; naturally, the patient was upset. There was no history of active tuberculosis or of a positive skin test. I reported the case to Public Health and held multiple (three) lengthy phone conversations with the patient, stating that it was most likely tuberculosis but that there were other possibilities. (Fungal or bacterial infection.)

    What I'm trying to say is, I spent a fair amount of time on this case. I should also emphasize that the patient looked remarkably healthy, clinically speaking (no high fevers, coughing up blood, etc. etc.). Let me also reiterate that the total amount of time elapsed so far is 48 hours - or less - since the X-ray reading.

    Late yesterday afternoon I got a fax from a lung specialist requesting STAT authorization for two tests (a bronchoscopy and a CAT scan of the chest) for this patient. I did not refer the patient to this doctor, I did not know who this even was until I looked up the physician in our on-line database. I had heard nothing about this appointment from the patient and received no phone call from the M.D.

    I took no action yesterday because I did not have time. Today I called the patient who stated that he/she (no pronouns here for security reasons) had gone to see the physician in question based on a recommendation from a family friend. "I wanted to get treatment as soon as possible," stated the patient.

    "Why didn't you call me? I've been calling you for the last two days. What made you do this instead of calling me and asking for a referral?"

    "I was uncomfortable that you referred me to Public Health. The only thing they will do is see if I have tuberculosis. I wanted to find out what was going on, and I don't want to get treated at the county hospital."

    "I talked to you about what the other possibilities could be. Remember? We spent a lot of time on this. I want to find out what's going on as much as you do, but I wanted to get the tuberculosis question settled first. If you had been really sick I would have put you in the hospital if necessary - you weren't even running a fever. I've been working with Public Health a lot this month on another tuberculosis case and I thought they could do the job most efficiently."

    "Well, I pay thousands of dollars for insurance and I have a right to get treatment I think is appropriate."


    Readers, let me tell you something. One way to really piss your doctor off is to pull the "I have insurance therefore you owe me" argument. Every day I see patients who have insurance, patients who don't and patients who used to have insurance but are losing their coverage; I try to treat them all the same. You do NOT deserve Treatment X or Test Y because you have insurance; you deserve it because you are SICK. This patient, with a legitimate problem, just lost all credibility with me based on that one sentence and on not giving me the compliment of a phone call to inform me of their concerns and intended actions. Unfortunately, that took nothing away from the fact that a problem existed here that had to be treated.

    On further review, it turned out that the specialist in question did have a contract with us - though it wasn't a doctor that I work with on a regular basis. The tests ordered, I had to admit, were perfectly appropriate in the circumstances. I wrote the referrals - after I made it clear to the patient that I was really pissed off and that I thought he/she had acted in bad faith.

    I didn't mark the referrals STAT, though; I downgraded them to "Urgent." Because, yes, I'm just that petty.

    Piss a waiter off and you run the risk that he'll spit in your food, unprofessional though that is. Piss a doctor off and... do you even want to go there? We aren't saints. I know that there are many, many docs out there who act like mini-tyrants and treat their patients like dirt. I try really hard not to act that way and not to have control issues (I can't deny that that may have been a factor in how I feel about this). But to put a lot of work in on a case, to try to be there for a patient, and then to get treated like this - yeah, if I were a waiter, at this point I sure as hell would spit in their food.



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