Corporate Medicine

Yesterday I had the classic experience in corporate medicine.  
A woman arrived without a letter from the referring physician. This is not unusual nowadays because the referring physicians are seeing so many patients so quickly they have by and large dispensed with the practice of calling or writing the doctor to whom they refer patients, so it's up to the consultant to divine what the issue might be. 

This particular lady said "the office" had referred her, which mean a nurse or secretary called her on the phone and told her to see me. 

The patient was taking prednisone for temporal arteritis and she felt "punk," by which she meant, it turned out after much questioning, she was unable to walk up a hill or do any of her customary exercise without feeling exhausted and her heart raced now and then. She had read on line the prednisone might make her adrenal glands atrophy, which could cause her to be fatigued. Apparently, she had phoned her doctor's office and someone had spoke to someone and eventually a blood test was ordered and was found to be abnormal and someone in the office (maybe a nurse, perhaps the secretary, possibly the custodian answering a phone) decided to send her to an endocrinologist.

The blood test was an ACTH level, which was almost unmeasurable. This is a predictable and expected result of taking prednisone.  So, I had solved the "problem" that is, I did what any self respecting 3rd year medical student could have done: I explained the abnormal finding. Next patient. 

The thing is, the patient was still feeling crummy and had palpitations. So, I did what I had been trained to do in internal medicine residency: I listened to her heart. Her first heart sound was of variable intensity. That could mean atrial fibrillation. 

I asked my administrator if we had an EKG machine and she said, "You are an endocrinologist. Why would you need an EKG machine?"  

Turned out, we did have one, which the cardiologist uses when he is in the office twice a week. 

She was in atrial fib. She had never been  known to have this heart dysrhythmia before. The thing about A fib is-- it doesn't do the heart much harm, if the ventricular rate is not to fast.  But it can be complicated by stroke. That's the problem with A fib.

I called her primary care doctor, who happened to be a cardiologist, and he said he was embarrassed she got referred for that ACTH, which apparently was not his idea and he asked me to send the patient to the ER so they could get the A fib treated and the patient feeling better.

My younger colleagues were appalled at how I handled this case.

"You listened to her heart?  You did an EKG? You're an endocrinologist! You solved the problem; you should have moved on to the next patient. Your numbers will be way low if you keep doing stuff like this."

"We're supposed to be internists first, and specialists second," I said.

"Yeah, like in the dark ages. Now, you got to worry about your numbers. Enter the patient into the electronic medical record, check the boxes, move on. And what if you had misread the EKG? Think of the liability. Oh, corporate would have been delighted with that. How long did it take you to do all that?"

"Well, by the time we dug up the EKG machine and the call to the PCP and explaining it to the patient, about an hour."

"Were you late for your next patient?"
"Yes, and the one after that left because I had got behind in my schedule."

"So, your numbers for today were down. You got all into being the hero doc and you you cost corporate money."


The doctor who instructed me thusly is not quite half my age.
"What ever happened to 'Put the patient first?'"
"I don't know what you are talking about," the young doctor replied. "Welcome to 21st century America."

From the mouths of babes.