Wednesday, March 12, 2014

Working 9 to 5

This is a very long document however the chronology is summarized on Page 6.

This unfortunate,now deceased, man developed a mass in his testes for which he consulted a physician at a walk in clinic on two separate occasions months apart.  On the second occasion he was referred to a general surgeon.  After 3 months he had not heard from the general surgeon's office but developed back pain for which he consulted the same physician (you know where this is going).

He was sent for a battery of tests which showed something ominous.  An urgent CT of his pelvis was ordered and performed.  When he didn't hear about the results he went back to the walk-in clinic but was told that the doctor who ordered the test no longer practised there and he was given an appointment to see another doctor who at the radiologist's suggestion ordered an ultrasound of the scrotum, making the diagnosis of testicular cancer.

He was referred to a urologist who worked in a multi-urologist practice grandly called an Institue of Urology (this seems to be an affectation of urologists, our city's group also calls itself an institute).  Unfortunately far from being an institute, this institute, like the one in our city is just a bunch of doctors who share office space.  It turns out that the urologist he had been referred to was on a long vacation and nobody was looking at his referrals to see if there might be something urgent like a testicular mass.    This, our patient found out when he phoned the urologist's number and got a recorded message.  Another urologist was located and surgery was performed urgently with follow up scheduled at the local cancer centre.   Two months passed between the presumed diagnosis of testicular cancer and the actualy surgery.

Two days later our patient noticed swelling of his legs.  After not being able to reach his surgeon (or presumably whoever was on call for the Institute) he went to the emergency where the ER doc ignorred the red flags of leg swelling in a post-op patient with cancer and sent him home where he died suddenly the next day.

The report doesn't say what the autopsy found,  My money is on a pulmonary embolus but what do I know?

I can be a little smug about this because I am an anaesthesiologist and we don't have to deal with patient care issues like this.  Trust me, if there was a way to blame anaesthesia for what happened here, we would have been blamed.

This report hit the press a month or so ago and generated some outrage until people forgot about it and started worrying about important things like Justin Bieber and the Olympic Games.  

Like most catastrophes there was a chain of small mistakes resulting in a huge fatal mistake.

1.  The patient went to a walk-in centre.  This may be because he didn't have a family doctor or maybe just because his family doctor wouldn't give him an appointment when it was convenient for him.

2.  Instead of thinking, "hmmm testicular swelling in a young man... rule out testicular cancer", the walk-in doctor referred him to a general surgeon.  Now in the old days, some general surgeons did urological procedures and this is probably still the case in the developing world which is where the walk-in doctor is most likely from.

3.  Presumably instead of having his receptionist call the office to arrange an urgent referral, he just faxed an illegible referral form which the general surgeon's secretary couldn't read and so just put it on the pile with the rest of the illegible referral forms.

4.  After discovering that the man probably had (mostly likely) metastatic cancer, instead of then getting on the phone to a urologist or an oncologist, walk-in doctor #2 faxed in an illegible referral note to the a urologist at the Institute.  Presumably nobody was looking at this fellow's referrals.  On the other hand did they even have a mechanism for triaging really urgent referrals.  Probably not.  And of course trying to get any specialist on the phone is next to near impossible.

5.  Not knowing exactly how he presented to the ER and what degree of leg swelling he had or what investigations the ER docs did, it is hard to comment on what happened there.  At the very worst,the ER doc may have just thought, "OK he is seeing the oncologist tomorrow, he will take care of this."  Because you know, getting a venous doppler, phoning the urologist or starting someone on heparin is a such a drag.

Canada has socialized medicine.  What we really have are hundreds of physicians practising independently, the only commonality being the single payer.  While the government and individual physicians are spending milions on EMRs, these unfortunately do not talk to one another.  It is quite likely that even if the emergency room doctor worked at the same hospitall where the surgery was done, the operative report might not have been available to him on the computer because it hadn't been typed yet.  The urologist's consult would definitely not have been available.

The headline above was that our registrar reminded doctors that medicine is not a 9-5 job which unfortunately may come as a surprise to many doctors.  He also took the time to reminisce about his long ago career as a general surgeon and the excellent coverage he provided.  I actually worked with him 15 years ago, before he bailed for what lead to his  current job, and for a general surgeon he did provide pretty good care to his patients.  He didn't mention however, that he worked in a teaching hospital where his house staff fielded, screened and triaged all his calls for him.  He might have seen into the future how house staff coverage was going be eroding and that might have been why he bailed.
I have been practising for 31 years now and maybe I am looking back at the past with rosy glasses but it seems that we used to communicate better and actually try to serve our patients a little better.  There may be reasons for this.

There is the whole boomer, Gen X and Gen Y thing and how they look at life differently.  I could expound on this but others have done so more eloquently.

More and more there has become more of a divide between primary care docs and specialists.  Primary care docs used to work in hospitals, they largely don't now.  Primary care docs and specialists used to train together at least as junior staff.  Now primary care docs and specialist train in their individual silos with no interraction.  There used to be more respect between the groups.

Finally the licensing bodies have gradually over the years lowered the bar in what is considered standard on communication between doctors and after hours coverage.  While I suspect most people are already in the process of changing this, I can predict pretty safely that if I call most family doctors' and quite a few specialists' phones after hours, I will get a recorded message directing me to call 911 or go to the emergency.  Further many patients that I see in the pain clinic tell me that their doctor has gone on vacation with no replacement.  This used to be only patients from rural areas with small numbers of doctors, increasing I see it in patients from the city.  A couple of summers ago, one of the medical clinics in the town where I have my dacha placed an ad in the local paper announcing they were closing their office for all of July and August.  There was no suggestion where their patients would be going.  Who can blame them, when you live in a resort community what a drag having to work?  Likewise patients have told me that they have shown up at their family doctors office, only to find he has left town permanently.

Further complicating matters is the fragmentation of care.  Patients have slices of their care provided by various specialties and subspecialties.  There is very little communication between them.  They obtain their urgent care from a walk-in clinic where they see a different doctor every time.  It may be fine to parcel out pieces of the patient but conditions overlap and who is in charge when the shit hits the fan?  I am guessing the answer is "not me"

We talked about this at our Medical Advisory Committee meeting last Friday.   A couple of the surgeons stated that their patients had been admitted to hospital with complications of surgery and they had never been notified.  They only found out when the patient showed up for a follow-up visit or didn't show up because they had died.  A pulmonary specialist complained that patients he was following would be admitted to internal medicine and he was not called.   A lady from admin who was there, stated that yes, they had known for years it was a problem and that not calling a doctor who might actually know something about the patient's condition frequently prolonged the patient's hospital stay.  She didn't say why admin had not tried doing something.

Anyway it strikes me that the horse has long left the barn on this and I am interested in how our licensing body is going to play this out.  I am attending the semi-annual representative forum of our provincial medical society this weekend and it should be interesting.

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