Mixed Messages.

Day 26. National Blog Posting Month.

My professional trust has been shaken. There was an incident at my office last week. A patient was given a test result over the phone by one of our front desk staff without consulting with the physician (wasn’t me) first. This patient was told his results were all normal but in fact one critical result was not yet reported and he wasn’t told that. So he was under the assumption that all if his tests were back and reported as normal. You can imagine his surprise when he was called back a few days later and told that the one test he wanted a result on was in fact was never done by the lab and he needed to repeat it.

The physician, my colleague, was quite upset by the encounter and rightly so. This physician confronted out staff and explained in no uncertain terms that any test result given to a patient must first be authorized by the attending physician. Obviously the assumption is that our staff are not trained in interpreting results nor would they know if all tests that were done were in fact reported back.

Yet on that same day, this colleague was covering lab results for another colleague (not me) and instead of reviewing the labs as requested, the physician delegated the task to the front desk staff. “Please look at Dr.X’s labs and tell me if there’s anything abnormal I need to look at.”

Excuse me?

On the one hand, the front staff is not competent to give test results to patients without express consent from the attending physician while on the other, the same staff member is competent enough to review test results for the physician?

What?

I have reviewed this physician’s labs on countless occasions when they’ve been away on vacation.  I have stayed late doing so as I have an equally busy practice. I am flabbergasted that this physician would actually delegate this task to our staff when they told our colleague they would review the labs. I don’t even know how to address this with the physician, I am so disappointed and upset.

Juggling.

 

 

 

how-to-juggleIt’s been a week.

I’m covering for both of my colleagues this week. We have a locum physician covering their practices as they are off for the summer, but she is off as well, on a much deserved holiday. So it’s been a bit crazy.

It’s not so much the patient flow – I can handle a fully booked day with a few add-ons; it’s the lab results and the follow-up required.  Doing my own labs and clearing the decks for the day is sometimes hard enough but doing it for two other practices? That’s another story.

It’s 5pm and I just finished seeing all the patients. I start reviewing one colleagues’ lab results. Oh look. A 50-year-old woman whose platelet count is 23,000!  (Normal range is 145,000 – 400,000). She is a new patient to my colleague and so I have to spend 20 minutes reviewing her old records, only to find that yes, her platelet counts have been low in the past but apparently the previous doctor never bothered to investigate it.  It’s now 5:20pm.  I call the patient and start asking her a bunch of questions – yes, she’s been bruising a lot for no reason (and she’s complained about this to the previous physician for the past few years!!!), yes she is tired all the time, yes she is having bleeding from her gums.  Oy.  She likely has ITP.  I got her an appointment with the hematologist for next week.

Then there was the patient with a CK level of 10,000.  CK is creatine kinase; it’s an enzyme that breaks down skeletal muscle.  I didn’t know the patient, so I had to review the chart.  She’d been complaining of vague abdominal pain and muscle aches for a while now.  All manner of testing (abdominal ultrasounds, CT scans, etc) failed to reveal any pathology. She’s not on any prescribed medications (that would be easy, right?). And of course,  there wasn’t a baseline CK to compare, so now I’m supposed to figure out why she’s breaking down muscle.   Or is she?  After a phone call with the patient, I find out  she’s taking a protein whey supplement as she trains for a 20 km obstacle course run.  Hmmm … I’m not so worried anymore – the elevation in CK is likely a byproduct of the protein supplement, so I told her to stop it and recheck the levels in a few weeks.  Crisis averted! But the entire exercise took 15 minutes out of my day that I never got back.

While reviewing another colleague’s lab results, I see a very low white cell count from the end of June ordered by another physician and our office was copied on the result.  The WBC (white blood cell count) was 1.6 (normal range —  4 – 11 x 10 **9).  The differential shows a very low neutrophil count (these are the white blood cells that fit bacterial infection).  I reviewed the patient’s chart – he’s not on any medications, has no history of malignancy – so I cannot for the life of me figure out why he’s neutropenic.  Of course I have to call him now.  Has he had unexplained fevers?  Who ordered the blood test and has he been informed of the result?  The answers to both those questions was no.   Great.

And then there’s the lovely 60-ish-year-old lady who comes in for her annual check up.  Her gynecologist does her Pap tests and orders her mammograms (she had breast cancer 10 years ago).  I have repeatedly told her I am happy to do her Pap tests and order her mammograms, but she likes the gynecologist and wants to continue to see him.  Fine. Great. No problem.  So at her check up, as I’m checking her blood pressure in her left arm, I noticed a rather large bulge coming from the side of her neck.  I don’t even remember what her blood pressure was, I’m sure it was normal, but mine certainly wasn’t.  I assess the area and it’s a large mass arising from the left side of her neck. It seemed too low for a lymph node but also felt like it was in the supraclavicular fossa.   FML.

 

 

 

 

 

 

Back in medical school, I was taught that if one felt a lymph node or a mass in the supraclavicular region, it was cancer until proven otherwise.

The fact that my patient didn’t even know there was a growth there is concerning.  A painless mass that goes unnoticed (or is ignored) is concerning.  The fact that she’s already had a history of breast cancer is concerning.  The ultrasound report confirming the mass and suggesting a CT or MRI is concerning.

Could this week get any worse?

Why, yes, it can. It is kind of ridiculous that I could sit here and write about another four or five lab results.   But you know what?  I just can’t talk about it anymore. This week needs to be over.  I need to stop saying yes.  I have to learn to say no.  I can’t be the one to cover for both of my colleagues at the same time anymore.  Something is going to get missed and I don’t want it to be on my watch.  One doctor covering almost 3000 patients is insanity. Yet, I agreed to this knowing full well I’d likely feel this way. What is wrong with me???  And why is this July the worst July on record for patients?  The summer used to be dead slow.  WTF is going on??!

Rant over.