Speak no evil

The referral was stupid.  The physician I had consulted about my patient thought so, and made no bones about telling the patient’s father so.  It was a waste of time, the question at hand could have been answered easily without it, and when the patient returned to my office for a follow-up all of this was conveyed back to me.

I was, of course, livid.

So I sent an assiduously polite e-mail to him, sweet as pie and apologetic as possible.  I expressed how very sorry I was for having consumed his time with a referral that could have been avoided, explained my reasons for having referred in the first place, and assured him that I would direct future referrals elsewhere if he found it troublesome to deal with them himself.  It was the e-mail version of smiling with a lot of teeth showing.

And I received an assiduously polite and apologetic reply in return, full of regret at the miscommunication.  Of course he would never dream of questioning such a referral, and was obviously delighted to be a resource for that and all future patients.  I am not entirely sure I believe that he did not intend to communicate to the patient’s father that he though the referral was stupid, but we left things at that.  (I also wonder if he had been aware that we are both on staff at the same hospital, which was made clear when I used the e-mail system we share to communicate with him, and if he might have been a bit more circumspect had he known.  Which is a question that shouldn’t need asking, should it?)

Now, he may very well have been right that the referral could have been avoided.  In fairness, as part of this particular patient’s work-up I had ordered a test which the consultant informed me could have been skipped, and it was good to learn this so I can avoid unnecessary tests for other patients in the future.  He’s the expert in that area, and I was glad to have been given useful information.  But it would have been much nicer if he’d refrained from expressing his opinion that the referral was stupid to the patient and family, and had communicated in a professional manner with me directly.

This little back-and-forth sprang to mind when I read this article about doctors speaking ill of each other at the “Well” blog at the Times:

Over the last decade, few issues have garnered as much interest among health care experts as disrespectful behavior among doctors. While sociologists have devoted careers to researching the topic, it wasn’t until the 1990s that the medical profession itself began to take serious note.

Spurred on by the increasing complexity of medicine, concerns about safety and patient satisfaction and an ever-growing urgency to contain costs, the Institute of Medicine convened a national panel of health care experts to discuss “the chasm” between what could be and what was actually being done for patients. In 2002, they published an ambitious report that called for a “sweeping redesign of the entire health system.” Realizing that vision, said the panel, would require, among other changes, better collaboration and cooperation among physicians and the creation of a “culture of respect.”

[snip]

Researchers trained three actors to portray “standardized patients” with advanced lung cancer who had recently moved to town after being treated by another doctor and who remained unsure about their diagnosis or prognosis. The actors, carrying medical records written to reflect only universally accepted guidelines of care, made a total of nearly three dozen office visits to various family physicians and cancer specialists working in the community.

The actors were not told to elicit the doctors’ opinions about their previous care; but after analyzing transcripts from each office visit, the researchers found that in 40 percent of the consultations, doctors went ahead and spontaneously offered their opinion anyway. A tiny percentage of these comments were neutral; a third were supportive. The vast majority, however, were unabashedly critical, with the doctors’ comments ranging from “Hell, you don’t want to trust doctors,” to “This guy’s an idiot!”

I am of two minds about this.

On the one hand, I am usually loath to criticize another medical provider, even if I disagree with their management.  When I do have qualms with how one of my patients was managed in another setting, I usually couch those concerns with an acknowledgment that I wasn’t there when the care was delivered so I’m not in the best position to know what the exam looked like, etc.  I think it’s bad policy to be overtly critical of other medical providers under most circumstances, and I would never say something so blatantly unprofessional as “this guy’s an idiot.”

But.

There have been times when patients have gone to some clinic or emergency department and received care that was unmistakably substandard.  A safe enough example would be those patients who come for follow-up with a prescription for albuterol syrup, a treatment for asthma that was discarded before I even entered residency.  (Prudence dictates that I keep other, more egregious examples to myself.  Suffice it to say that I have other, more egregious examples.)  And, while I will try to speak in a respectful manner, there is no way I am going to discuss the patient’s treatment without telling the parents that albuterol syrup is no longer considered appropriate care and that they shouldn’t use it.

If, to use the language in the article I quoted, a patient has received “accepted guidelines of care” then I can’t imagine why another doctor should denigrate it.  But surely professional courtesy shouldn’t keep me from telling people who come to me for medical care if I think it’s been genuinely deficient in some way.  Would lawyers refrain from telling their clients if they’d received poor counsel elsewhere?  Would a CPA go over a sloppy set of books and not mention their sloppiness?

Doctors shouldn’t badmouth each other when they have no cause to do so.  The ones quoted in the study who did so, given that the ersatz patients had gotten ersatz treatments that were correct, appear to be in the wrong.  But doctors are all too human, and we make mistakes.  And if a mistake has been made by another medical provider on one of my patients, I see no reason why I shouldn’t say so.