The Problem of Expertise

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.

A Good Day

1. Wake up rested on one's own.
2. The coffee is smashing,
3. And the biscotti crisp.
4. There is time to do yoga.
5. Nothing awful has happened in the world, yet.
6. There is no argument before school and work.
7. The commute is calm with music one loves.
8. The work day goes smooth with just enough challenge.
9. Dinner is tasty and nutritious, too.
10. The day is done with some lines written and read before bed.

No Respect for the Generalist

One of the parts of my job is holding the triage phone. This is not something I enjoy. It feels like folks call me for a way to reach other folks and finagle transfers to our teaching hospital. I am not at my best on the phone and phone tag is irritating.

My first conversation with the outside hospital doctor started with bare bones introductions before she asked me if I was a nephrologist because she wanted an expert opinion on whether her patient needed hemodialysis. Now, this was a woman with lots of comorbidities who had heart failure which was responding well to diuretics but her creatinine has creeped  up. We discussed her care and decided that there was no indication for urgent hemodialysis.

My very next call from another outside hospital was for another person with newly diagnosed congestive heart failure with a prior history of chronic lymphocytic leukemia. Now, here even before our introductions, the doctor blurted out, asking me if I was an oncologist. I told him that I was a primary care doctor working in the hospital. We reviewed the details of the patient's history and concluded that he needed management of his shortness of breath before looking at further oncologic management.

It is shocking to me that generalists don't seem to trust their own clinical judgement. Care for a patient often degenerates into a consult-a-palooza where a lot of specialists opine about diagnosis and therapy without a leader of care so that therapy may not always be in the best interest of the patient. This is a common scenario which plays out daily in our hospitals and reflects poorly on our internists.

Something Isn't Right


Woke up anxious and looked at my phone
Wrong thing I know-- but there it was again
Violence unbridled-- lots of folks dead, done
I made sure not to look at the news again.

A Wasted Day

There have been so many of them

Morning -- Noon-- Afternoon--

Work And Work And Work again

The first shift,

The second shift,

Remember the milk

And the after school stuff.

That is just the way the cookie crumbles.

Time passes,

Trees change.

From the noisy, freezing air conditioning,

to over the top heating,

to the children's new tees.

Facebook reminds me-

A year ago you posted this picture and

you see this shiny eyed

Little boy

Who loved you

Once Upon A Time.



Heat Wave In India And Hot Yoga

Every evening, I watch the news- and everyday this week, I learn of the heat wave in India. About the people that have died. How poor folks can't be indoors, can't afford air conditioning or maybe even a house. Or how there is such a great water shortage that one has to pay for water and even so there is no guarantee that the water is safe for drinking. 97 million people in India don't have access to clean water.

I thought about all this during savasana (corpse pose) at a hot yoga class. The class - intermediate vinyasa- advertised the temperature in the studio being 99 degrees. In India, temperatures have soared to nearly 120 degrees. I have free access to clean tap water which I drink throughout the class. I feel strong, rejuvenated after my class. What exactly have I done to deserve it? I have worked hard but the laborer in the fields around Delhi has also worked hard, if not harder than I have.

Is Geography Destiny?

Weekends

The American Way, or at least what I think of as the American Way, is to work hard and live large over the weekend. So, what does one do when one has been a lotus eater through the whole work week? Can one justify living large over the weekend, then? That is my big question for myself especially as a mother and hard working full-time doctor. Anyway, I cooked breakfast, exercised and now I am ready to hit the beach for some quality Socal living. I'll justify my existence later. Ciao!