17 January 2012

Surgeons behaving badly: a rant

I recently saw a patient who had had a major surgery at a downtown medical center. He had done fine initially, but at about 2 weeks out, the patient started having fevers and chills. He saw his surgeon in follow-up and was diagnosed, reasonably, with a UTI and started on antibiotics. Unfortunately, he got worse and presented by EMS to my ER quite ill indeed. It was clear that he needed to be admitted and possibly to have another surgery.

In this case, I was pleased that the patient and his family thought the world of their original surgeon. "Dr Smith was great, so thoughtful and kind and he knows all about my problem, you will call him, won't you?" "Oh, I have to be admitted and maybe another surgery? Can you send me to Dr Smith? He's the one I really trust."

No problem, I thought. So, on this holiday weekend, I call The Big Medical Center and get hold of Dr Jones, who is the partner of Dr Smith. I explained the situation and laid out the facts. Dr Jones surprised me by ignoring the fairly obvious clinical conclusion and asking, "Well, what do you think should be done?"

"I'm not a goddamn surgeon, which is why I'm asking you, you passive aggressive jerkwad," I didn't say. I did suggest that the patient needed to be admitted and perhaps explored versus observed. I waited for him to sigh and say "OK, why don't you send him down here. I'll arrange a bed."

"What do you want me to do about it?" he replied. It was becoming clear that he viewed the fact that the patient had landed in my ER, and not his, to be a stroke of luck, as the patient was my problem and not his. Oh well, I had given him the opportunity to be graceful and accept the responsibility.



"I think we should send him to The Big Medical Center and you should take a look at him. I honestly don't know whether you need to operate or not: that's going to have to be your decision."

"Why would you want to do that? You have [my specialty] at your little hospital. Have your surgeon look at him and I am sure they are competent enough to manage the issue." His voice was dripping scorn at this point.

"I don't think the family would be happy with that. They liked Dr Smith a lot and they really want to go back to The Big Medical Center, and for continuity of care it probably is in his benefit to do so."

He wasn't being put off so easily though. "Well, it's the holiday and Dr Smith is not going to be in the hospital and I don't know anything more about this patient than your surgeons do so he might as well stay there. Besides, his insurance probably won't pay for the ambulance transport -- does the family really want to be stuck with that sort of bill?"

Now I'm fuming. I'm pissed because this guy is doing everything he can to block this late-night admission, and moreso because his points are more or less correct. Still wrong on the global level, but accurate on the details.

I had no choice but to force the issue: "Look, I can keep him here, but if I do that, everybody is going to be unhappy. My surgeon is going to be unhappy that he's had somebody else's complication dropped in his lap. I'm going to be unhappy that I have to force him to take this case. The patient is going to be unhappy that they were not cared for at the institution and the medical team of their choice. And Dr Smith is not going to be happy that his patient was refused admission by his partner." I did not add that I was already unhappy that I was having to bully and threaten him into doing his bloody job.

He relented, getting in one last passive aggressive jab, "Fine. I'll accept him, since you're clearly incapable of caring for him up there."

I took a deep breath, swallowed some bile, and thanked him and set the phone down. I got what I wanted, the patient was getting the care he needed, and so I had won, at the expense of twenty-five points of elevated blood pressure and the need to work on the heavy bag for a while.

My experience is that there is nothing a surgeon hates more than having somebody else's trainwreck dropped in their lap. Many times I have had that conversation, where I call our specialty surgeon and he snarls at me, "Why is this patient here? Why didn't they go back to wherever the original case was done? Can't you send them back? I'm not fixing that guy's complication!" And frankly, I understand that perspective. The second surgeon is often offended that the primary surgeon is shirking - the ethos among surgeons is generally one of responsibility, though, and even mild territoriality. They usually want to be called about their patients and they usually want to have their patients sent to them when there is an issue down the road. I like that.

Which is why it was so maddening that this guy, who was partners with the original surgeon, was blocking the referral. It was his responsibility. He agreed in advance to cover his partner's cases, as they do for him. And here I am having to bully, badger and hector him into doing his bloody job. Gah.

I should point out here very clearly that this was an unusual event, which made it rant-worthy. My general experience with surgeons, en masse, is that they are very good about taking responsibility for their complications. The few who shirk this responsibility, though, give the rest of them a bad name.

13 comments:

  1. really true~
    I often admire your views on things, do share your opinions, thoughts and feelings, even if it is a rant:)

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  2. sometimes it seems as though people see hospitals like Burger Kings-you can go to one anyplace in the world and get the same hamburger.

    why on earth someone with a postoperative problem would go to a hospital different from the one where the surgery was performed is utterly beyond my comprehension. and yet it happens all the time!

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  3. I've been on the other side of this - I had a partially extracted wisdom tooth that the original dentist no longer wanted to touch. "Take Tylenol", he'd say, then hang up the phone. (One root was still in my jaw, having a grand time with dry socket.) Eventually the (perhaps naive) student dentists (bless them) at RWJ School of Dentistry's clinic saw it, diagnosed it, treated it, and, uh, called in their classmates for observation. I'm quite grateful they were willing to see that bad job, believe me!

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  4. One Gen Surg staff I worked with put it best: you break it, you buy it. The second you cut into that abdomen, it becomes your responsibility to account for any and all accidents/occurrences that happen to the patient afterwards.

    Which is why the decision to cut in the first place has to be made carefully.

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  5. I would call the original surgeon as soon as he is available and ask him if he knew what a dick his partner was being to his patients.

    His partner's behavior was increasing his risk of a malpractice suit.

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  6. patients often don't know that EMS will take you the the nearest hospitals if you look sick. If the patient's desired hospital is nearby and the patient looks OK, then EMS will sometimes bypass the nearest hospital to honor the patient's preference. But for a patient who looks unwell or has a time sensitive complaint, they go to the closest hospital by protocol.

    In my experience, this is by far the most common reason for these "wrong hospital" presentations.

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  7. As a student I watched this unfold just before a holiday weekend...

    The patient had been admitted from extended care to the floor not looking good. The trauma center downtown wouldn't take the patient back stating they had "already" treated. I watched the surgeon's face drop as I told him what I had found during my nursing student head to toe assessment before he entered the room. That was the day I lost my innocence about just how things can be...

    -SCRN

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  8. @ShadowFax: also, sometimes EMS drops a patient off that could very well be transported to the hospital of their choice so they can get back to their (bed/dinner/xbox) faster, leaving us with the pissed off family asking us why their family member was brought to "this hospital."

    Nothing to do with degree of illness or time sensitivity - just plain, old IDontWanna...

    Sigh.

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  9. Seen this play out many times over the years, watched many a vein bulge on an ER doc's forehead. I am often surprised by the restraint shown by most ER docs.

    Of course the few times I've seen one blow a gasket on the phone it has been entertaining, if not productive. Except perhaps as a stress relief for the doc.

    Another thing that entertains me is how pissed off the receiving doc is when he sees the patient, even venting their bile at me on occasion.

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  10. Shadowfax, be sure and send a link to this post in an email to the Medical Director of the ED at 'The Big Medical Center'. Something tells me he might have a pretty good idea just what to do with this information.

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  11. I think I've had that exact same conversation more than once.

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  12. As an academic who spends time in rural clinics. I have seen some of the most pompous, arrogant, abusive, destructive, frankly asshole behavior come from my cohorts in the ivory tower. My last weekend call I was sitting in the ICU and a pediatric intensivist was ranting to his colleague on the phone loudly on the phone so that anybody could hear, that he had to admit an asthmatic child from a "moron" at a some critical outreach hospital. Never mind the patient was going straight to the PICU (guess the "moron" must have had a clue) and the referring hospital and no pediatirc critical care. When he got off the phone I just looked him in the eye and shook my head. I find this behavior by academics disgusting. In my experience having done both private and academic practice, most ivory tower types should be REQUIRED to spend time in rural america to get an idea what it is like when there is not every specialty at your beck and call and residents/fellows to do most of your work for you. Then they may have some clue as to how much of a jackoff they really are in these situations.

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  13. PS:
    I agree with the commentator that states you should call the original surgeon to give feedback on his jackass partner. The only way to change arrogant academic assholes is to call them on it. Then like any bully, they will turn tail.

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