Recent conversations have reminded me about 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 reminded me of his poor health.
I came across his cancer doctor in the hospital corridor and we talked a bit about his diseases and management. I shared that he wasn’t looking well. This lead 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 corridors and clinics of the hospital. All of us can be imagined as a system where many different organ systems have to work well on their own and together for us to feel 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 sometimes the implication that I have taken care of “my organ system”; now if things aren’t going according to plan then the problem lies in another organ system and so we need another consultant.
This begins what I call a consult-a-palooza. 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.
Common example of this being someone in Renal Failure and Heart Failure where the Cardiologist will recommend a diuretic drip while another consultant may recommend holding diuretics. It can be quite challenging to reconcile these opposite therapies unless the Hospital Medicine doctor has a viewpoint and can explain their perspective logically.
In these days when collegiality is uncommon, it becomes difficult to reconcile opposing therapies especially when they are recommended for the same patient. It can be impossible to reconcile recommendations for complicated patients with multiple diagnoses and comorbidities.
Part of me really enjoys this puzzle solving aspect of Medicine and part of me gets quite frustrated by the communication problems, therapeutic delays and human suffering that come along with every patient that is a diagnostic and therapeutic conundrum.
Sometimes, these occurrences feel like Medicine’s version of “Not my problem”. Well, ultimately it affects the patient so it is everybody’s problem and one that we cannot slice and dice our way out of. Expertise is supposed to help get the best care for our patient and not shrug off a problem.
I always feel that this sort of thing ought to be the special strength of an Internist and we ought to rise to the challenge of being able to diagnose and care for the medically complicated patient and never offer the cop out of: “this isn’t my problem”. I hope generalism continues to rise to the challenge of the “complicated patient” for whatever reason that they happen to be complicated.
