Wednesday, July 27, 2011

Neurology, 2011

Dr. Grumpy has lost his neurology mojo over time.

Actually, I shouldn't say I've lost it, as much as it's been worn down by red tape.

Yesterday I turned away a good hospital case, and told them to find someone else.

The patient was insured. The patient was interesting. Not some run of the mill chronic back pain case.

28 year old guy admitted for abdominal pain and weight loss. Large mass found (possibly lymphoma). Within 2 days of admission he developed 2 separate cranial nerve palsies, on opposite sides.

Now, I know you residents and medical students are out there, holding up your hands and yelling "Oooh! Oooh! Mr. Kotter! He could have meningeal lymphomatosis with cranial nerve palsies! He needs an MRI and spinal tap."

Hell, you think I didn't know that? Like I said, these are the interesting cases that make the job fun.

So why did I tell them to find another neurologist?

Here's why:

The patient had seen another neurologist (who didn't come to my hospital) about a week before. He'd had an MRI done as an outpatient. He'd had a spinal tap done as an outpatient.

And yet, no one, including the patient and his family, had ANY FREAKIN' IDEA about which neurologist he saw (beyond "his office was on the west side"), or where the MRI was done, or where the spinal fluid had been sent for tests.

I don't care that someone else had already done the key parts of the work-up. I'm not looking to stand up as the great Grumpy, solver of the unsolvable. Any competent neurologist would know what to do.

And getting results is reasonably easy IF you know where to fax a release.

But in order to get the answer here I'd have had to try to track down a neurologist, an MRI facility, and a laboratory. And there are no shortage of any in Grumpyville.

And from personal experience (particularly involving tracking down labs) I knew it could easily take an hour or more of phone time to do this. I've found that when you want something specific, delegating it to an order in a chart ("please get outside labs from Planet Phlebotomy") will often get you nowhere, or some results you didn't want. So I'd likely be doing the calling, and getting transferred between departments, and then cut off, and having to call back... you get the idea.

When you have a full-time office practice, and a family of 5, adding an extra hour or two to the day isn't something you want to do. Especially when you're going to get paid the same amount for the consult no matter how much work you put into trying to track the results down.

And so I quietly told them to call another neurologist.

I still like what I do. But the realities of time, money, and frustration can dull the scientific curiosity of anyone. Even me.


Alex Dreamz said...

Poor Grumpy - you're looking at it from the wrong perspective - you haven't lost mojo, you've gained insight. A patient (and potentially attending family, I assume?) who cannot remember specialist, facility, etc, is most likely also going to have difficulty remembering treatment specifics, medication instructions, and probably how to write a check ;)
You just know a problem child when you see one, and are wise enough to avoid the grey hair that comes with such!!

Carolyn said...

I completely agree with Alex Dreamz - you saw trouble coming and sidestepped it and that is a good thing, not a loss of mojo. Good for you - now you are free to handle the case of someone who cares enough about their own health to remember what doctor they saw last week!

Rathskeller said...

Your reasoning makes good sense -- but since the patient is insured, the insurance company couldn't give you the neurologist's name (or perhaps the referring physician's name)?

B. Perky said...

Ah, the joys of a passive-agressive patient. Just love the ones who make you start from scratch. Good for you for passing on this one.

Grumpy, M.D. said...

Rathskeller- it's not that it couldn't be done, it's the time factor involved in doing it.

GunDiva said...

Hey patients! Take responsiblity for at least part of your own care. Knowing who you saw and where you had tests done is part of that responsibility!

That said, I think that the majority of patients think that we can just plug into the interwebs and get any information we want about them. The commercials for EHR certainly make it seem so. Never mind that each system has their own EHR that NEVER plays nice with an outside system's EHR.

I'm in a mood today, sorry to take it out on your patients. Good think I don't work for you, huh? :)

Anonymous said...

Ibee, I don't think you lost anything. There just comes a time in one's career where you have to "pick your battles!" Your kiddos will only be little for so long, and if this is what you felt was best, then good for you.

I don't see that this would be any different than when MD's are closed to new patients, or like my Neurologist whose considered a HA Specialist, is closed to new HA patients. Unless, he is the doctor on call for that practice, and is called for a consult after hours. In our area hospitals there are Hospitalists that take care of those patients, though.

Knowing when it's just too much is NOT a BAD quality to have.

OldSquid said...

Maybe they'll get lucky and find the neurologist that saw the guy in the first place.

Or you could have said, "track down the MRI, spinal tap, and neuro report and then I'll consider consulting."

Frantic Pharmacist said...

That's what we are sometimes, the Ultimate Babysitters. And I thought it was bad when people didn't know where they had their prescriptions filled....

Not House said...

That's very unfortunate for the patient, but at the end of the day, exactly like you said, the realities of the situation made it nigh impossible to do your job as you needed to.

Anonymous said...

Ok, the guy is in the hospital. Lymphoma has its own horrors and the complication does make it interesting.
But why the *&^% did Some Other MD let this poor guy walk around (all the tests were OPt)?
Fascinating or not, I think even Ed can smell (neat for a fish) the malpractice case coming.
You are fine to not consult on the case until all the peices can be put in a row. The Pt isn't going to get any less care, right?

Ben S said...

Yaks sound better every day.

Anonymous said...

If I was your office nurse, I'd do it for you!

Solitary Diner said...

So much of medicine is the hunting down and calling - it wears a person down after a while. I wish patients would appreciate how difficult they make doctors' lives (and how much they jeopardize their own care) by not keeping records of the tests they've had and the doctors they've seen. So frustrating!

ER's Mom said...

Hey Ibee,

Good for you! The tribe is little for just a few short years and the hassles of crap like that takes years off of you.

It's not worth it.

ps my WV is outed. ;)

GlassHospital said...

Hey Dr Grumps-

meaningful post. and shows how far we have to go with EMR compatibilities, etc.

would make a great op-ed for a newspaper (remember those?) but you'd likely have to drop your cloak...though maybe not----why not submit to times-NY or LA? or Annals of Int Med--they love this kind of first person thing.


Watercolor said...

Yeah, I learned that the hard way as a patient.... Neurologist sent me for an MRI at a lab across the street from their office then a few weeks later to a local hospital for a spinal tap. Hospital wanted copy of the MRI before they would do the tap. Apparently, I was supposed to bring it on a disk. No one told me. And I had no idea what the place was called. I did, though, know my neurologist's name so they were able to track it down asap. I didn't even know the MRI place was a separate business from the hospital until that day... lol.
"It's the place across the street from the doctor's office tower"
"Place X or Place Y or Place Z"
"ummm..... eeeerrrrr.... what?"
"nevermind. sigh. who's your neurologist?"
Talk about feeling like a stupid patient without meaning to...

Anonymous said...

Sounds like what you need is a medical student to do scut work
-A medical student who's spent dozens of hours over the past year tracking down OSH lab results

Andrew_M_Garland said...

Maybe the whole family had meningeal lymphomatosis with loss of orientation, subdued planning function, and acute memory loss.

This could have been a publishable incident. (smile)

cliffintokyo said...

Most of us reach a stage in life where it is time to forgo scientific curiosity and to start enjoying being paid for what we do. % of the 'working' population don't even have that luxury.
Don't quit on us; keep those synapses firing!
Reminder: Curiosity killed the cat.

Minerva said...

Oh how I WISH I could turn away patients like this at the pharmacy!

I need you to fill my white pill. "I got it last at Pharmacy X or Pharmacy Y... or maybe it was Pharmacy Z. Who was giving away $50 gift cards last March? I don't remember the doctor. What is the medicine for? Maybe high blood pressure--- or it could be cholesterol? No! I need it TODAY!"

I need a sound-proof screaming booth at my pharmacy installed ASAP.

Glen said...

In Texas, more than half of insurance carriers require pre-cert. If you *have* to start the records chase, try online inquiry for that carriers pre-cert department. Usually it will give the type of MRI authorized, the facility and the ordering doctor.

If there is an efficient way to chase down lab results, I've not found it.

I'm not convinced EMR would be a big help. Have a good primary care physician to oversee your care and referrals is probably a better answer.

On the plus side, such a records chase lets you enjoy a great variety of music on hold, and can expand your vituperative vocabulary.

Anonymous said...

Okay, now. Patient's side of the story. I had a brain tumor in high school.

I didn't know what was making my head ache, why I was puking all the time, couldn't think straight nor remember a darn thing-and I was taking calculus, physics, English/German literature, etc. I wasn't faking it! Olfactory hallucinations, stumbling, couldn't walk up stairs.

My folks were freaked. This was a family of 10. Nothing like this had ever happened in the family that kept only aspirin, oil of clove, and horse liniment in the medicine cabinet.

The family doc sent me to endocrinologist--I had blood tests, psychiatrist--I had psych exams, gastroenterologist--I had upper and lower GI studies, and finally a neurologist, who sent me for X-rays (this was back in the day before MRI or CT). He had an idea of what was going on and ordered the definitive diagnostic tests, but I had to travel out of state, where I went to a big, BIG hospital, and heck they were sending me everywhere.

I had no idea of where I was going most of the time in the big BIG hospital as my glasses were often put away for 'safekeeping'. Maybe only about 25 residents and specialists saw me. I had about every test that was necessary and then some.

The 10 hour surgery went well and my mother was there, then flew back home while I convalesced. I was given medicines for this and that and was allergic to several of them with alarming reactions. I do remember the surgeon's name, and the place and I remember what some of the attending's faces looke like when I returned for follow-up to the big BIG hospital (clinic) in 3 months.

Blue Cross/Blue Shield health insurance was a relatively new concept at the time when my father joined the union, and his insurance covered it all along with my grandparent's funds to help with travel, so my mother as a college-graduate was able to kept track of most of it.

Today, a patient would be sent from one family doc that he might or might not know, to another, then subsequent visits arranged by the office based on the patient's insurance, and whatever financial situation available. The insurance in dictating decisions where and how the patient must get from A to B SHOULD be handling the circus, but only recently have PBM's started offering case managers to their beneficiaries.

I feel the MD pain, but am not entirely sympathetic as I'm a doctor in an health-related field and have a pretty good grasp on how things work right now, but pity more the dumb patients.

haldol said...

GlassHospital, it is true that it is interesting. But if he submits it to a normal newspaper he is going to get super flamed by the masses that no nothing about what medical personnel go through. To some of the readers, it will be illuminating. To others, it will be a ranting point for those durn selfish doctors drivin' up our health care costs. So many patients blame everyone but themselves for their problems.

Grumps, if there was a shortage of neurologists in your town it would be different. But there isn't, so let someone younger who will get excited take it.

Anonymous said...

Ibee, you haven't lost mojo. You're just seasoned enough to want to practice medicine, not paperwork pushing. You've seen enough exciting things that you can let one pass you by when it's not worth the effect on your life. That's maturity, not weakness.

An RN who is at that point too. "Go ahead young grasshopper- I'll be right here helping the family and dealing with big-picture bed placement issues that won't occur to you til after the iabp is in and the transport-for-emergent-CABG crew that I called is here. Got your back, kid- you go have "fun." "

The Shrone said...

If there is such a thing as patient and doctor chemistry, we'd be a perfect match! I've been to numerous doctors and hospitals over the course of almost 30 years. I have made a point to keep track of who has treated me and where, even bringing in medical records to initial visits and relevant diagnostic tests, to find out that:

* The CT scan/blood work/colonoscopy was not done in the manner that Dr. Bowel prefers, or is too "old", so it's all useless and will be done over.
* Dr. Bowel hasn't had time to review my medical records (and never will), or that Dr. Bowel was completely unaware that my medical records had been received, which definitely means they will never be reviewed.
* Dr. Bowel is only mildly interested in who has treated me before. It's just a CYA formality.

If I ever need a Dr. Brain instead of a Dr. Bowel, I think we'd get along just fine! I had an MRI of my brain done in 2001 and I still have the hard copies. I've kept them because I think it's kind of cool to have pictures of my brain, but also for "just in case" I'd ever need them.

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