The freedom to admit someone because it was the right thing to do

The most high-powered rotation in my medical school was endocrinology. There, you got to see things most doctors never come close to diagnosing themselves. Uppsala University’s Akademiska Hospital served as a referral center for the Swedish population north of Uppsala, an area the size and shape of California.

Back in the seventies, laboratory testing wasn’t as sophisticated as it is now. We didn’t have CT scanners even at the major hospitals, and MRIs weren’t in use yet.

The endocrinology ward accepted referrals from northern Sweden for evaluation of suspected pheochromocytomas, Cushing’s Disease, Wilson’s Disease and other exotic conditions. The chief, Professor Boström, had established the most appropriate workup, or “utredning” (investigation), for each type of problem, and patients would undergo these tests in rapid succession with almost real-time interpretation. Within two or three days, they would be on their way home with a diagnosis and treatment recommendations for their local doctors or follow-up appointments with Uppsala specialists.

The other feature of the endocrinology ward was that every day, the chief or his deputy would do rounds with the junior doctors and doctors in training who carried out the testing protocols. Each patient’s progress was presented to the chief, who would suggest modifications or additional interventions. That way, each patient had the benefit of having the professor of medicine oversee their care. This is the way hospital rounds are done everywhere in Sweden; the head of the clinic directly supervises every patient’s care.

Two differences in how health care is delivered in American hospitals stand out:

First, patients seldom get admitted for testing here. People end up having serial imaging tests as outpatients. Someone with vague upper abdominal pain may go for an ultrasound that shows a normal gallbladder and borderline dilatation of the common bile duct and slightly irregular texture of the liver followed a week or two later by a CT which shows only a harmless fatty liver but confirms bile duct dilatation. Next, they might have an MRI that suggests a blockage of the bile flow somewhere in the head of the pancreas where there appears to be a tumor. By that time, the patient is feeling worse and is suddenly jaundiced and finally gets admitted for an ERCP that provides a tissue diagnosis of pancreatic cancer.

Second, the quality of care you receive depends on the hospitalist(s) in charge of your care. They work as a team, but many of them are young or temporary hires who practice without the day-to-day involvement of hospital clinical leadership. I see patients admitted for the same thing to the same hospital being handled completely differently because somebody else was on duty when they came in.

In Sweden, it seems that even today, bed-nights are relatively inexpensive, and patients are sometimes kept simply for “observation.” Here, bed-nights seem to be a rare and exclusive commodity that cannot be wasted. So we make the patient with chest pain that went away come back on Monday for his stress test if it happens to be Friday. And we get paid the same whether we discharge someone early or end up keeping them a little longer because of the bundled payments of DRGs.

And, oh, here we have to justify “medical necessity” for every admission. So we make an older woman take her laxatives at home and have her grandson drive her 50 or 100 miles to the hospital in the predawn hours for her early morning diagnostic colonoscopy.

In the socialized system in Sweden, there always was the freedom to admit someone because it was the right thing to do, even if you had to use the diagnosis “causa socialis” (social reasons).

I hear there’s even now a diagnosis code for that (ICD-10): Z60.9. I remember using it during my early years in practice there.

Sometimes you need to do what’s right for the patient. Actually, we should always do what’s right for the patient.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

Image credit: Shutterstock.com

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