"Ain't my job..."

One of the things that I'm quickly learning through my preceptor sessions is that there is a pervasive attitude of "it's not my problem" present in the medical community. I've seen patients bounced around between 3-5 doctors telling them different and obscenely wrong bits of information, ignoring complaints of pain and even missing completely classic presentations of their specialty's bread and butter. It seems that the oncologist is the place that people come for complete care addressing all of their symptoms. It pretty much horrifies me every week.

Case in point came today: A pleasant elderly gentleman came in for a routine oncology follow up expecting some blood work. I'm expecting a fairly simple history, a well correlated physicial and about 30 minutes of discussion about what the blood work showed. Instead we we're launched into his current symptoms of his last 18 hours of orthopnea, sleeplessness, dry cough and A Fib. Concerned that it was his third episode in 2 weeks, he presented at a local heart clinic that morning. The cardiologist got the same history that we did, listened to the heart sounds and sent this poor patient on his merry way with a slight change in his meds and an order for an ECHO later that week. Great, the guy is in congestive heart failure and a CARDIOLOGIST let him walk out the door to buy himself a trip to the ICU on a vent before the end of the week.

So we start taking the history, and by the time we get through the Chief Complaint (step 1 for those who don't know) my preceptor looks over at me and then takes control. He specifically targets every key point in the history for someone in CHF. He ends the history, looks at me, points his finger and says in his thick accent "This is a VERY CLASSICAL PRESENTATION...you'll never forget this." We start the physical: laterally displaced PMI, elevated venous pressures, rapid pulse, bilateral crackles at the lung bases, pitting pedal edema, 3/6 holosystolic murmur, essentially the textbook CHF presentation...you get the idea. The Oncologist calls the Cardiologist to tell him that his patient is in CHF, he's being admitted to get it back under control. Here's the kicker: After this whole ordeal is through, the patient asks my preceptor if the Cardiologist did a good job. My preceptors response: "Out of professional courtesy, I'm not going to comment on that."

Not surprisingly, this whole event was quite unsettling for me. How could a man in the midst of acute onset congestive heart failure be allowed to leave a cardiologist's office when he is quite clearly about to buy himself a vent in the next week? How could a second year medical student elicit more pertinent points in 2 minutes of taking a history than a cardiologist? It is just plain irresponsible to let someone in this shape leave your office just because he's old and not in acute distress. If I take one thing from this whole physical diagnosis class it will be the importance of a thorough history and physical. Yes, the time crunch and meeting patient quotas are an excuse, but letting someone this sick leave your office is absolute negligence and laziness. A quick listen to the lung bases in a patient with a holosystolic murmur while your steth is in your ears still may have been a good idea? A quick "How are you?" Perhaps listening to the patient would have given you the clinical picture of someone in heart failure? I'm angry that people like this are allowed to practice medicine, but more so I'm scared of who will be taking care of the people that I care about.

No comments: