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'Not my Problem': How NOT to Care for the 'Complicated Patient'

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Recent conversations have reminded me of an experience I had with an oncologist whose patient I was helping to care for in the hospital. He wasn’t doing too well. He looked terrible and his laboratory tests reflected his poor health. I came across his doctor in the hospital corridor, and we talked a bit about his diseases and management of them. I shared that he wasn’t looking well. This led to a shocking, memorable response that still rings in my ears.

“Whatever it is — it isn’t his cancer that is killing him.”

Even today, as I write this, I am shocked at the slicing-and-dicing that goes on in the hospital’s corridors. The hospital system is like the human body: it needs many different organ systems work well on their own – and together – for it to be “healthy.”

As a generalist in the hospital, I take care of a wide variety patients and this is a recurring theme in my interactions with specialists. Usually, when there is diagnostic dilemma or therapeutic conundrum, rather than approaching the problem with a wide lens and humility, there is the tendency to approach the problem with the attitude: “I have taken care of ‘my organ system’; if things aren’t going according to plan, then the problem lies in another organ system, and we need another consultant.”

This begins what I call a “consult-a-palooza” — i.e., one consultant asking for another consultation and before we know it, contradictory recommendations start flowing down the pipeline. Usually, this doesn’t lead to the best patient outcomes.

A common example of this occurs when someone is in renal and heart failure. The cardiologist will recommend a diuretic drip, while another consultant will recommend holding diuretics. It can be quite challenging to reconcile these opposite therapies, unless the hospitalist has a viewpoint and can explain the difference in perspective logically.

In these days where collegiality is uncommon, it is difficult to reconcile opposing therapies, When they are recommended for the same patient, it can be impossible, especially if the patient is complicated (e.g., has multiple diagnoses and comorbidities).

Part of me really enjoys this puzzle-solving aspect of medicine, but another part of me is quite frustrated by the communication problems, therapeutic delays, and human suffering that comes with every patient that is not a diagnostically or therapeutically simple case. Sometimes, these cases feel like medicine’s version of “not my problem.” And ultimately, it affects the patient, which makes it everybody’s problem — one that we cannot slice-and-dice our way out of.

Expertise is supposed to be used to help get the best care for each patient. It is not supposed to be used to shrug off a problem. I always feel that this sort of thing ought to be the special strength of an internist; we ought to rise to the challenge of diagnosing and caring for the medically complicated patient. We should never be using the “this isn’t my problem” cop-out. I hope generalists can rise to the challenge of the “complicated patient.”

Dr. Singh works in a Veterans Affairs hospital, primarily in an in-patient setting. She has no conflicts of interest, financial or otherwise. The viewpoints expressed above are solely her own, not her employer's.

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