Blog | Monday, June 4, 2012

New oxygen requirement overruled without a reason

In the age of hospitalism and diagnostic related groups there has been an audible push to get patients out the door and spend less money. Whose money? The hospital's.

I often hear things from residents and hospitalists such as: "Don't order that test, it won't change our management," or "Let's discharge the patient as they can have that worked up as an outpatient." These statements generally irk me for a number of different reasons. Foremost our job is to diagnose acute and chronic diseases in our patients not to maximize the profits. Secondarily, this mindset interferes with the process of learning from our patients. Thirdly, it can put an unnecessary work load on the outpatient internist.

Don't be mistaken, I understand the importance of not ordering unnecessary tests, minimizing waste in health care, and avoiding harm by chasing incidentalomas.

Can a liver biopsy be done as an outpatient? Definitely. Can a resident learn more from caring for a patient with liver failure, arranging for the biopsy as an inpatient, and then relaying that diagnosis to the patient instead of turfing the work-up and never truly learning from that patient? In some instances it seems we are training our future internists to think no further than the walls of the hospital, creating inpatient triage-ists.

Ideally a trainee learns by following the arc of an illness, seeing the presenting signs and connecting them to a final diagnosis. This grounding of symptom to diagnosis provides that essential experiential learning that allows the trainee to continue on to be an independent physician. By isolating our training to the inpatient setting and thinking of medicine in an inpatient silo we lose. We effectively become the inpatient equivalent of emergency room physicians.

In the outpatient setting I've been on the receiving end of patients who have been admitted and diagnosed with a symptom but no actual work up or diagnosis was made. I'm put in the position of starting over (which I'm actually more than happy to do, as that's the reason I became an internist) and trying to sort out what is really going on. My clinic staff are then put in the position of arranging for consultations and arranging for testing that could easily have been performed in the inpatient setting, a setting where tools of diagnosis are a hallway away.

While attending on a patient in a local hospital my team was caring for a patient who had been sent into the hospital for an anxiety attack and was found to be transiently hypoxemic by EMS. There was no other evidence of hypoxia throughout her triage in the ED, nor overnight while on the floor. The nocturnist had ordered a V/Q and HRCT to rule out PE and PCP PNA respectively. The next morning she was noted to have hypoxemia only ambulation.

My team told me they wanted to discharge her on oxygen and have her follow up with her primary; her work up had been negative, after all. I re-framed the case to them from my perspective and probed for supporting evidence of why they thought she should be discharged with a new oxygen requirement without a diagnosis. "You are allowed to order any test, consult any consultant, just don't send her home until in your mind you have constructed a reason that she is hypoxic."

Now these residents are hard-working and efficient, albeit too efficient and too hard working, moving people through the system without thinking. I'm just waiting for someone to suggest to me that we don't biopsy a mass because it's probably cancer and thus it won't change our management. Until then, my team and I are going to focus on treating our patients, diagnosing them with the diseases they do have while not looking for ones they don't have.

Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident. This post originally appeared at his blog, Musings of an Internist.