When Clinic Patients Become Inpatients

There it was..the sound I really did not want to hear on a Friday afternoon, the sound that will be associated with a feeling of utter despair for the remainder of my human existence...the sound of my pager. I was on call for a city hospital that was an hour commute from where I was, a hospital I was told we "rarely" get calls from. There was a patient with a badly infected foot that I needed to come and see that day.

When I arrived at the hospital, the patient seemed to recognize me right away, though I did not recognize him. He said I had seen him in clinic 2 weeks prior, but I still had no recollection. It was definitely possible, though it is nearly impossible for me to remember all of the hundreds of patients I see in clinic. The great toe on his left foot was badly infected. He was a diabetic who was not taking care of himself. He was only 38, and had already been through two previous amputations. The toe was swollen and dusky. When I examined it further, I noticed there was some crepitus...an indication that there might be gas in the tissues..gas gangrene. The patient had come in with a fever, but at the moment, he did not have one. His white blood count was not elevated (an elevated white count is one sign of infection), but clinically the toe was badly infected. This patient needed that toe amputated, or the infection would likely spread further.

I called my attending. He was on his way to a nursing home where he sees patients, and would not be available. He told me to call one of my other attendings. I called the second attending, and he told me he was at a different hospital waiting for a surgical case to begin there. I called a third attending, and he told me that he would not do the case after 7pm because he had dinner plans...I knew this case would never go before 7. He told me that since the patient did not have a white count or a fever, the case could wait until the next morning.

It was a Friday, and the hospital does not take add on cases for the weekend until the morning of the surgery. I returned to the hospital the following morning at 7:30 am. The patient's morning labs now showed a highly elevated white count. He had been running fevers all night. I added the case on, and was told it would go at 9:30. I called my attending, and he arrived just in time. The toe was amputated, but it seemed it may have been too late. The patient pointed out a few painful bumps on his leg. I examined them, and realized they were likely collections of pus...the infection had already spread up his leg. The general surgeon was called in, and he incised and drained the areas at bedside...but it was worse than I thought. The patient's white count continued to rise, and he continued to have fevers. A blood culture came back positive. This infection had already reached well beyond the patient's toe.

The patient was started on new antibiotics, but he continued to have pain in his foot and leg. A week had already passed, and it was now Friday afternoon before a holiday weekend. I spoke to the PA on call and asked her to order an MRI to rule out any deep abscesses (collections of pus) in the patient's foot or leg that may need to be surgically drained. I was told that no MRI would be performed until Tuesday because it was a holiday weekend. I continued to monitor the patient's vitals and labs until Tuesday finally arrived. I called the PA again to see what the status of the MRI was. She told me that the radiologist had called in sick, and there was no one available to approve an MRI..it needed to wait until Wednesday. The patient finally had his MRI revealing an abscess on the top of his foot that was drained the same day. Smaller abscesses on his leg were also drained. The patient improved slowly over time, and was eventually discharged from the hospital almost a month after his admission for an infected toe.

This is what happens when clinic patients become inpatients. No one has any particular interest in them. This is not the private patient of a doctor, or a patient that has good paying insurance. This is an uninsured or Medicaid patient that is passed through a system of salaried physicians that have no incentive to treat them as quickly as possible. Why spend your evening in a hospital cutting open a smelly foot when you have dinner plans?

Sometimes This Stuff Gets Emotional

You know that feeling when you are really happy about something, and you feel like you are completely unable to hold it in? The kind of feeling where you let out a little scream and shake? It is that feeling you get in high school when the girl or boy you really like asks you out, or when you get a letter in the mail that you were accepted to that college that you really wanted to go to. You feel like everything in life is going the way you want it to. Unfortunately, I can not remember the last time I had that feeling. Residency will do that to you. When I wake up on a work day (the large majority of my days), I am usually overcome with a feeling of dread as I realize what I have facing me that day...overbooked clinics, surgical cases with high strung attendings, incredibly sick inpatients, rude hospital staff, and co-residents that are just as stressed out and cranky as you are. Most of the inappropriate comments come from your attendings, and you eventually learn to let them role off your shoulder. A battle is just not worth it. You want to get through these next couple of years as smoothly as possible, and move on with your life. Unfortunately, there are those occasional moments where an inappropriate comment comes from your co-resident...you are not exactly hanging out with them on weekends, but you expect a little more from the people that are floating in the same boat as you.

Recently my co-resident...one I am pretty friendly with...poked himself with a suture needle in the operating room. It turned out that the patient was HIV +, and my co-resident needed to go on anti-viral medication for 2 months. After the surgery, he commented that when he is finished with residency, he will refuse to ever perform surgery on a gay male patient. He does not know that I am gay, but this should not matter. This was something I chose to keep to myself at work, and I guess I am glad I did! I did not realize how completely ignorant my co-residents could be! These are the people who are supposed to be objectively treating patients! These people are doctors, they are supposed to be intelligent! I lashed back with the statistics (one's he should have already learned in medical school)...worldwide, women accounted for 50% of all persons infected with the HIV virus. Even in the United States, gay men only make up 53% of those infected with the HIV virus. He shut his mouth, we moved on. I could deal with the surgeons in the OR joking that I am trying to touch their asses as I tie up their gowns, or the orthopedist's gay impression that he loves to perform...but complete ignorance was more than I was willing to handle. So, there was no little scream or a shake, but if felt pretty good to finally speak up. I think I am going to try it more often.

These are Clinic Patients

They get to clinic early in the morning, often before any of the staff have arrived. They do this because they realize they need to register early, or they might face a 2 hour wait to be seen. If they are lucky, they are able to secure a seat in the crowded waiting area, otherwise they stand in the doorways and hallways waiting for their name to be called. They are one of 40 patients waiting to be seen by one of two doctors during a 3 hour clinic session. If you do the math, this leaves roughly 9 minutes for the doctor to see each patient, and this includes the time needed to document and bill for the visit. The doctors these patients are seeing are actually residents. The attending physicians presiding over the clinics sit in a back room on the computer or phone, signing the charts as the residents bring them to their desk with hardly a glance at what is actually written. They are getting paid by the hour, and therefore have little concern for the patients themselves. As long as they are there, they are getting paid. The number of patients seen or the procedures done have no bearing on their salary, so why put in the effort? Many of these patients have no insurance. If they do have insurance, it is either medicaid or medicare.

I take a chart from the massive pile and call in the next patient. He is young male in his late 30s with diabetes. He seems shocked when I explain to him that he has a large diabetic pressure ulcer on both of his feet. He tells me he can not see his feet well, and thought that whatever was there had already healed. He explains to me that he has stopped taking his blood pressure and diabetic medications because he ran out and is unable to get an appointment with his medical doctor for months. This is common, as all of the clinics are overbooked. I suggest he go to the ER, realizing this means a 6 hour wait time since all of the other patients who can not get appointments with their medical doctors are down there as well. He realizes it also means a huge medical bill in the mail in a few weeks. I explain to him that he needs a special boot to wear to offload the ulcers so they can heal. He has no insurance, and the boot costs $150. He tells me he can not afford it, nor can he afford to take off from work in order to stay off his feet. He has few options. He is the uninsured working poor. I build a makeshift pad for his shoe with some felt padding, realizing this is only a temporary solution. I feel helpless as I send him back to the waiting room.

I pick up the next chart and call in a female in her 40s. She limps into the examination room. I review her history and discover that she is suffering from a chronic ankle sprain. She has no insurance, and is unable to afford the $700 lace up brace. She is already struggling to pay off the bill from the MRI that was performed a few months ago. She cries as she tells me she can not take this pain much longer. She is looking to me for an answer, but I do not have any cheap ones. I explain that she would probably benefit from physical therapy. She tells me that even with the payment plan, this costs $40 per session, or $80 per week. I apply another soft cast to her leg, one I realize will become dirty and fall off long before her next appointment in clinic. I explain she may want to consider surgery to repair the torn ligament in her ankle, but this would also require speaking to a hospital based financial counselor to discuss payment options. I send her back to the waiting room as well.

I sit in the quiet examination room and take half a moment to contemplate these patient's situations...I can not take too long, the massive pile of charts is still waiting, and it keeps growing larger. I count the pile..20 more. These are clinic patients..the poor, the uninsured..or just another number in the pile my attending wants me to rush through so he can leave before the traffic gets heavy. I am tired.

Surgery Just for the Heck of It

Last week I was going over the list of inpatients on our service with two of my attendings when we came to a diabetic male who was admitted with fever and chills. The patient had an ulceration on the bottom of his foot resulting from something called Charcot Foot. Diabetics often develop what is called peripheral neuropathy...bascially, the peripheral nerves become damaged, and the patients develop numbness in their hands and feet. This not only affects the nerves that are responsible for our touch sensation, but the nerves that are part of something called the sympathetic nervous system as well. This results in the break down of bones in the foot with multiple fractures and dislocation of the joints. The patient often develops something called a roker bottom foot, or a bony protuberance on the bottom of their foot. Over time the skin overlying this area breaks down and becomes ulcerated...and so, this was the case for this patient. A very complicated (but high paying) foot surgery is a charcot reconstruction, or the surgical attempt at putting the foot back together again. Let me add here that this surgery does not have a great success rate. As soon as my attending saw that there was a patient on our list (without even seeing the patient in person), he wanted me to talk to the patient and book him for a charcot reconstruction with an external fixator. This is basically a big metal frame that goes on the outside of the foot and has pins going into the bones of the foot. This would be a 4-5 hour surgery with a long recovery time. The other option, which would be less costly (pay less), and have a much quicker recovery time for the patient would be to simply cut away the bony protuberance on the bottom of the foot and close up the ulcer. The attending who wanted to do the charcot reconstruction made an attempt at guilting me into booking the case by saying "I thought you guys wanted to do surgery! This is a surgical program, so if you want to do interesting surgical cases, book this patient!" He wanted to put a patient through a complicated (and unnecessary) procedure to make a quick buck and brag about the recontruction he did. Sure, in the right hands, and under the right circumstances, this procedure would have its place...but this was not it! The patient was lucky that there was more then one attending involved, and the other attending intervened preventing the surgery from going forward. It is sad when medicine becomes more about money and experience rather than the care of patients.

Pharmaceutical Reps Are Not So Bad

I know these days everyone loves to hate a pharmaceutical rep, especially with news reports of them doing just about anything to get doctors to prescribe their medications...even using non-FDA approved indications as a selling point. Most of them are salesmen types with fake smiles and company cars, but here is the scary truth...some doctors could not survive without them, especially the ones who sell the surgical equipment. I recently scrubbed into an ACL repair (knee surgery) that was being done arthroscopically (as most are done these days). The representative from the company that was supplying the equipment to perform the repair was present, and to be honest, he should have been the one doing the surgery! Beyond the basics, the surgeon did not know how to use the equipment, and needed the rep to guide him through each step. It was stressful, scary, and 2 hours longer than it should have been. Most surgeons who use more than a scapel and some sutures will have a company representative in the OR with them from time to time...and some of them will have a rep with them almost all of the time. I also scrubbed a shoulder case with an orthopedic surgeon recently who decided he needed to use a certain piece of equipment to repair a tear in area of the shoulder called the labrum. The surgeon was looking to the scrub tech and the nurse to put the equipment together properly, but they did not know how. The rep was called, and rushed to the hospital so the surgery could continue. Perhaps surgeons should be forced into taking training courses before they are allowed to use this equipment on real patients...but that would be in the perfect world of healthcare, not the real world of healthcare.

Surgery Booking Day

We have clinic 3 days a week at a certain city hospital where the majority of patients are Medicaid and Medicare. As a result, we are told as residents that these are our patients, and we can treat them in whatever way we deem necessary. All residents need a certain number of procedures in order to graduate from the program. We are told that this hospital is the place to get our numbers by seeking out patients that we can book for certain procedures, and then performing those procedures on them. There is always an attending in the OR with us, so we are not actually performing the procedures alone, but these are clinic patients, and as a result, we are able to choose which procedures we want to do on the patients, and we are allowed to actually perform the majority of the procedure in the OR. I know that the idea of a resident performing a procedure on you is frightening, but this really is not the worst of it. We do need the exeprience in order to practice in future, and to be honest, a well trained monkey can perform most of these procedures. The difficult part of medicine is deciding which patients actually necessitate a procedure, and which procedure to perform on them. Unfortunately, residents always want to perform procedures because they need their numbers. Physicians are not going to let them practice on their private patients, so we practice on the clinic patients instead. We are told that one clinic day in particular is supposed to be our "surgery booking day." On this day, we are encouraged..well forced..to try extra hard to find patients to book for surgery, and if we do not book enough for that day, we are ridiculed by our attending for not trying hard enough. Something is wrong with this picture.

Defensive Medicine At Its Worst

On Friday I scrubbed a complicated orthopedic case that took about 4-5 hours involving the cutting of bone, and insertion of screws. Typically I order a post-operative x-ray while the patient is in recovery to make sure everything is in allignment and all of the hardware is in place. This is what I was instructed to do as a student and during my early residency training. I ordered the x-ray, and was beginning to preop the next patient when the attending physician approached me looking angry. "Never order a post-operative x-ray on my patients!! Do you understand?" Seeing that I responded calmly with an "ok, no problem," his tone softened.."you are just setting yourself up for a lawsuit" he said. "If you want a postoperative x-ray, take it in your office. There you will be the only person looking at it, and no one else will be able find anything wrong with your work." I am sure he thought he was giving me a good piece of practice managment advice..a tip on how to avoid a lawsuit, but in my mind, this was verging on the brink of malpractice. We are told that malpractice is anything that goes against the "standard of care," and the standard of care is to take a post operative x-ray in the hospital. We often hear about how doctors are scared into ordering too many tests on patients for fear of missing something and being sued, but here is an example of a doctor not doing something for a patient out of the same fear.