Growing Pains

“How arrogant can you be to say that dialysis is not indicated?”

The internist who was speaking to me came highly recommended to the family. I was the unknown hospitalist chosen by happenstance.

I cleared my throat and replied, “Well, in my experience, patients like her can’t tolerate it.”

“Don’t insult me like that. I’ve taken care of patients for 30+ years. Are you a nephrologist? Who are you to deny her this?”

Our tense conversation continued for a few more minutes and ended in a stalemate. With the family wondering why a nephrologist had not yet come, I felt my back was against the wall. I had a decision to make.

~~~

Our conversation revolved around a 89-year-old woman, who just a day or two before arriving at my hospital, was discharged from another hospital where she spent the majority of two months in the intensive care unit. After suffering several infections she was now dependent on a ventilator, and receiving nutrition through a feeding tube. Not long after arriving at the long-term care facility, she developed worsening respiratory distress and was brought to my hospital. She seemed to have developed a pneumonia. She was on maximal oxygen support, hypotensive (requiring a low dose of pressor support), and anasarcic. Despite this bleak picture, the private physician recommended a nephrology consult for the initiation of dialysis.

As a young hospitalist, I’m still struggling to handle situations when the private specialist recommends the assistance of a consultant, or requests a wide battery of tests when they don’t seem appropriate. Here, the recommendation was for aggressive care at the end of life, but sometimes it’s just about ordering dopplers after diagnosing a pulmonary embolism. It can come in the form of surprise consults that magically appear in the patient’s chart, or lab tests that magically appear from the ether.

Though the hospitalist has been around since 1996, sometimes it feels like the field is still going through an awkward teen phase– coming into its own sense of identity in a world that’s still not quite sure how to handle it.

A consulting physician may have a long history with this patient or may come highly recommended. So what exactly is the point of the hospitalist? How do you bridge the expansive divide between the colleague to whom you want to defer and the ideals of high value care to which you espouse? What do you do when you are the primary attending in name only?

I’m not sure yet. I’m certain that my inexperience leads to a degree of deference that might decrease over time. But I still see senior hospitalists roll their eyes saying, “Oh, with so-and-so, you just have to do it.”

A recent study in the Journal of General Internal Medicine suggests that we may beinappropriately using inpatient consultations. The implications of this can be profound and costly. Consultations lead to additional diagnostic tests and potential interventions that may put the patient at risk for complications. Length of stay increases, the costs add up, and the patient is no better for it. Hospitalists are aware of this; in some ways, this line of thinking isthe ethos of the specialty. I’m not sure the same can be said for outpatient practitioners actively involved in inpatient care. Widespread adoption of capitation and the ACO payment structure may lead to a rapid change in practices, but barring that, it seems like we’re in for several more years of growing pains.

I can’t say if this is a common issue, or one unique to a city with an unlimited supply of specialists (given the aforementioned JGIM article, one could argue that both statements are true). I just know it’s an issue that I’ll continue to face.

So I’ll need to find the right inflection when asking if we really need that consult or that additional scan. I’ll need to find the right way of saying, “You know, I think this can be continued as an outpatient.” I’ll need to make sure my voice doesn’t crack when I say, “I feel comfortable managing this myself.”

~~~

I ultimately relented and called the consult. The nephrology team agreed with my assessment. After extensive discussions with the family, the decision was made to transition to comfort care. The patient passed away peacefully that night.

**This is a fictional account based on real experiences so as to protect anyone who may have been involved.**

This post originally appeared on my blog, Medical Minimalist.