The patient is or isn’t a whole human being: FP vs. hospitalist


In the chest there was a great pain,
On the fingers, a cigarette stain
     I thought it was fine
     To go testing for Lyme,
The hospitalist thought not the same.

A week before the patient came to see me, crushing sternal chest pain had prompted a visit to Urgent Care. An abnormal electrocardiogram, sky-high blood pressure, sweating, nausea, and shortness of breath resulted in a prescription for an antihypertensive and a recommendation to see a primary care physician within the next week. Which the patient decided meant at least a week.
The patient looked sick, the chest x-ray showed the ravages of tobacco, the blood pressure still ran dangerously high, and the electrocardiogram had gotten worse. The joints of the hand were enlarged in an alarming fashion and the lungs sounded terrible. I called my colleague at the emergency room.

I regard the doc as much a friend as a colleague, and I asked to have the hospitalist call me after the patient has been admitted to investigate a couple of other problems.

The call came hours later. I expressed my concern that the patient had multiple other problems like fatigue, malaise, sexual dysfunction, pain in most joints and morning stiffness. I requested some lab be drawn in the course of the hospitalization.

I will grant that the list was pretty long and involved: sedimentation rate, CCP, TSH, rheumatoid factor, Lyme antibody panel, prolactin, B12, folic acid, 25-OH vitamin D, and others.

The hospitalist declined, concerned that the hospital wouldn’t receive reimbursement for the lab work as it didn’t relate to the primary cause for admission. He agreed with checking the thyroid.

Generally I avoid confrontation unlikely to improve things. With great diplomacy, pointing out the enlargement of the hand joints in a pattern suggestive of rheumatoid arthritis, I negotiated a Lyme disease test. I had to point out that tertiary Lyme disease could cause some of the patient’s heart problems.

Research has shown hospitalists get patients discharged alive quicker and for less money than family docs or internists. Those studies played a big factor in my group’s decision to stop hospital work except for OB and newborns.

I was the last amongst us to do regular hospital rounds. By the time I quit, last October, I was superfluous 90% of the time. But the other 10% of the time I did something unique that the consultants, with their narrower and deeper focus, didn’t. My decision came as a tradeoff, an attempt to improve the balancing act.

Tradeoffs rule in the real world. The doctor who sees the patient as a whole human being will probably not get the patient out of the hospital faster or for less expense than the doctor who only takes care of the patient in the hospital.

After my patient’s discharge, I’ll start the workup of the other problems. Most likely I’ll get the patient to feeling better, if not well.
I’m going to go back to hospital work eventually, though I’ve enjoyed the extra hour I get every day that I don’t make rounds. When I restart inpatient care, though, I’ll be in a position to limit my hours.

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