Blog | Wednesday, May 31, 2017

Does the patient need a feeding tube?


What should a medical consultant do when the referring physician wants a procedure that the consultant does not favor?

Of course, this sounds like a lay-up. The consultant, readers would surmise, should have a conversation with the referring colleague to explain why the procedure is not in the patient's interest. The colleague then thanks the consultant for his thoughtful input, and for sparing the patient from the risks and expense of an unneeded medical procedure. Then, a rainbow appears, songbirds tweet in harmony and the lion lies down with the lamb.

This is not how it works in real world of medical practice. I wish it did. Indeed, this issue has tormented me more than, perhaps, any other in my decades of work as a gastroenterologist. Many referring physicians request procedures from us—not our opinions—and expect that their requests will be complied with. This is the same mentality that all physicians, including me, have when we order a CAT scan. We generally do not consult with the radiologist in advance soliciting their opinion. We simply click “CAT scan” on the computer and then the magic happens.

On the morning that I write this, a physician has consulted a gastroenterologist to place a feeding tube in a patient hospitalized for this purpose. The patient is not only demented, but speaks no English. I called the son to acquire more understanding of his dad's condition. The patient has lived with the son for seven years and the son knows his father's feeding habits intimately, From time to time, he will have some coughing spells during meals, but this pattern has not accelerated. This is his normal pattern. The son related that his dad ate sufficiently and has not lost weight.

While I am able to connect the dots here that would lead to a feeding tube, for me this would require a lengthy caravan of dots to reach the referring physician's request. While I acknowledge that the patient likely has an impaired swallowing mechanism, it does not seem to pose a medical threat. Today is Sunday and the physician expects that the tube will be placed tomorrow.

I am covering over the weekend for the gastroenterologist who will assume the patient's care tomorrow. I did not schedule placement of a feeding tube. I requested instead that a speech pathologist, who is an expert in swallowing, offer an opinion. I think that was the right answer here.

Consultants know that all referring physicians are not created equal. Some welcome our opinions and others don't. Still others will punish us by cutting us out of their referral stream if we push back against their requests. This is a sad reality that I wish I could remedy.

I've certainly complied with procedure requests for tests that I might not have personally favored. This is not unethical, as long as there is a rational basis for the test, and the referring physician will use the information gained to adjust a treatment plan. Additionally, we consultants may be wrong. Perhaps, the referring physician's request for a colonoscopy is the proper test, even if we may not think so. No one knows it all.

Oftentimes, when folks are offered a peek behind the curtain, they are surprised to see what is happening behind the scenes. Anyone shocked here?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.