Patient Transfer and Push-back


The specialist just needed a chance

To vent his frustration and rants

Just as expected,

The referral’s accepted

Sorta what I thought in advance.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

I listen to the subspecialist’s voice on the phone, and I can hear the overwork through the bluster, asking me what I think he can do for the patient that I can’t.

The local term for what he is giving me is “push-back.”

I got a lot of it from Alaska Native Medical Center (ANMC) in Anchorage when I would try to transfer a patient. Even before I would pick up the phone, I knew I’d be attempting to enlist the cooperation of a physician close to burnout, with a service already bursting at the seams, analogous to pouring gallons into quarts.

In another century, in another country, I faced push-back from every rung of the hierarchic ladder at the academic hospital, when I had to ship out a patient with Reye’s syndrome. With vomiting, altered mental status and a swollen liver, I had made the diagnosis in less than a minute, and spent two hours proving it with lab, while late evening ticked into early morning. The medical student, intern, and resident all tried to block the transfer, but passed my call up the food chain.  The presentation to the chief resident, polished by the first three layers, included answers to the questions posed by the underlings in a coherent, rapid fire fashion.  In the silence of a 3 second pause I could hear something in him break, a resignation to the inevitable, and then he said, “Well, I supposed I’m going to have to accept the transfer.”

(I’ve not seen a case of Reye’s syndrome before or since; it disappeared when we stopped giving children aspirin. That particular patient recovered completely.)

I never ran into push-back in New Zealand. The physicians at the university hospital sounded fresh and cheerful every time I called.  But they have a different system; following the online flowchart weeded out the majority of unnecessary calls.

Today I catch the subspecialist in at the university hospital fresh, in the middle of the afternoon.  He fires off a list of questions, interspersed with complaints of thinly spread resources.  When he pauses, I confess I use a whiff of sarcasm when I say, “Would you like me to answer, or would you like to keep going?”

I figured out, early in my private practice years, that I spent more time and energy trying to avoid work than actually doing it, and I quit pushing back the ER docs when they called me to admit a doctorless patient. Because I built up good will, about every 7 years, when I really needed to, I could dodge an admission.

Between my sarcasm and the chance to rant uninterrupted, the subspecialist loses momentum, and in the silence over the phone, I can hear something break. Resignation replaces resentment when he accepts the admission.

I later learn he has a reputation as a good, caring, skillful physician in a badly understaffed situation.

I feel for him. I hope he doesn’t burn out.

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