Why a neurologist turned down an interesting hospital case

Dr. Grumpy has lost his neurology mojo over time. Actually, I shouldn’t say I’ve lost it, as much as it’s been worn down by red tape.

Yesterday I turned away a good hospital case, and told them to find someone else. The patient was insured. The patient was interesting. Not some run of the mill chronic back pain case.

28-year old guy admitted for abdominal pain and weight loss. Large mass found (possibly lymphoma). Within 2 days of admission he developed 2 separate cranial nerve palsies, on opposite sides.

Now, I know you residents and medical students are out there, holding up your hands and yelling, “Oooh! Oooh! Mr. Kotter! He could have meningeal lymphomatosis with cranial nerve palsies! He needs an MRI and spinal tap.”

You think I didn’t know that? Like I said, these are the interesting cases that make the job fun.

So why did I tell them to find another neurologist?

Here’s why.

The patient had seen another neurologist (who didn’t come to my hospital) about a week before. He’d had an MRI done as an outpatient. He’d had a spinal tap done as an outpatient.

And yet, no one, including the patient and his family, had any idea about which neurologist he saw (beyond “his office was on the west side”), or where the MRI was done, or where the spinal fluid had been sent for tests.

I don’t care that someone else had already done the key parts of the workup. I’m not looking to stand up as the great Grumpy, solver of the unsolvable. Any competent neurologist would know what to do.

And getting results is reasonably easy if you know where to fax a release.

But in order to get the answer here I’d have had to try to track down a neurologist, an MRI facility, and a laboratory. And there are no shortage of any in Grumpyville.

And from personal experience (particularly involving tracking down labs) I knew it could easily take an hour or more of phone time to do this. I’ve found that when you want something specific, delegating it to an order in a chart (“please get outside labs from Planet Phlebotomy”) will often get you nowhere, or some results you didn’t want. So I’d likely be doing the calling, and getting transferred between departments, and then cut off, and having to call back … you get the idea.

When you have a full-time office practice, and a family of 5, adding an extra hour or two to the day isn’t something you want to do. Especially when you’re going to get paid the same amount for the consult no matter how much work you put into trying to track the results down.

And so I quietly told them to call another neurologist.

I still like what I do. But the realities of time, money, and frustration can dull the scientific curiosity of anyone. Even me.

“Doctor Grumpy” is a neurologist who blogs at Doctor Grumpy in the House.

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  • http://openid-provider.appspot.com/madtexan@sbcglobal.net madtexan@sbcglobal.net

    I don’t blame you one bit for the choice.  I cannot imagine how the patient who is obviously experiencing a severe neurological problem cannot be responsible enough to remember who he saw the previous week.

  • Anonymous

    The reality is that a patient whose needs lie outside of the profit margin get left out.  I have a condition that isn’t a textbook case.  Most of the doctors I have seen don’t have the time to any thought outside the 10 minute office visit.

  • Anonymous

    This is a prime example of how patient and doctor needs and expectations don’t match.  Doctors, specialists, can spend a decade or more learning to be a doctor, but who teaches patients how to be patients?  Patients tend to expect more from doctors than doctors can reasonably accomplish because they don’t understand the processes doctors must accomplish to meet patient expectations.  Doctors need patients to take more responsibility for their own needs, such as tracking symptoms, medicines, labs, imaging, and office visits.  But doctors rarely tell patients what they need from them.  All parties are frustrated because their needs and expectations are not met. 

    Thank you, Dr. Grumpy for sharing this with us.  I’ll be using this in my patient education classes to motivate students to keep good records.

    But I have to ask, did you share your reasons with the family so THEY could track down the information? 

  • http://expatdoctormom.com/ Expat Doctor Mom

    The Beauty of life is choice.  And you chose not to care for this patient for better work/life balance etc.and that is a good thing.  I am a physician and respect myself and other physician’s more if they stand by what they feel is right.  A GI specialist (abroad) refused to do further workup on me after he found out I was pregnant even though indicated… Based on his culture, he believed he would do more harm than good. No, I was not happy but respected his decision and flew to London instead where I got my acute choly treated.

    I was not in your exact shoes so I don’t know what I would have done.  But in spending extra time for patients, I have written about this here: http://expatdoctormom.com/2011/07/11/doctor-is-in/  In this case I went the extra mile.

    I think the doctor patient relationship should be based on mutual respect and that patients should take part in knowing who they saw, what meds their on etc.  A woman sued a former partner and won b/c she didn’t find out she was hypothyroid for one year and claimed it made her depressed.  She moved, and none of her contact numbers were valid i.e. they had all become disconnected.  She won despite the multiple attempts (all documented) to reach her. Where was her responsibility in the matter? 

    I just read through your blog, very funny.  You sound jaded…. perhaps you should consider family medicine as I have largely never felt the way you do.  You should know I am completely kidding! The beauty of life is choice.

    Regards,
    Rajka

  • http://www.facebook.com/profile.php?id=1368068733 Jill Tucker

    What I don’t understand: why don’t you have staff to do this task? I wouldn’t be permitting the doc I work for to waste her valuable time on a wild goose chase like this.

    Also, I must say that it is unfortunate that you need a release in order to access information about a patient you are caring for. Our provincial medical information act allows caregivers to access such information without a release, in view of timeliness of care. (if you are a third party, like an insurance provider, it’s much harder of course)

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