State of our Healthcare System

July 6, 2016

How often do you have to manage inappropriate and unnecessary inpatient consults? Is there a way to fix the system?

When I was a resident, we were not allowed to merely order consults on our inpatients. Oh, no, if we had a patient that we thought needed to be seen by a specialist, we needed to call them ourselves. That meant that we needed to know the reason we were consulting the specialist, and we needed to be ready to provide them with the information pertinent to the reason for consultation. That meant we couldn't get a cardiology consult for everyone who showed up with chest pain or an ID consult for every patient with a fever. "Well, what are you looking for?" "What things have you considered already?" 

Later, when I was a fellow, we similarly expected the internal medicine residents to handle "bread and butter" endocrinology. My attendings believed that internists (and therefore, internal med resident) should be able to manage diabetes in the hospital. We were primarily called to see post-op pituitary patients, those suspected of being in thyroid storm, and other less common endocrine disorders.

I understood then that the purpose was to prepare the residents to be able to recognize and manage endocrine disorders. Later in my career, as a faculty member, when asked to evaluate residents, I have had to judge then on their ability to take an adequate endocrine history, perform the appropriate exam, order the correct tests to evaluate the problem and manage common endocrine problems; again to prepare them as attendings.

Which is why it baffles me, and frustrates me, when I get what in my opinion are inappropriate and unnecessary inpatient consults. Once I got a consult for an adrenal mass in a patient who was admitted for COPD exacerbation. At least, that's what the order said. I combed the chart and there was no mention of an adrenal mass in any of the progress notes. I looked through the radiology reports and there were no imaging studies of the abdomen. The patient knew nothing of an adrenal mass. I thought "maybe the order was accidentally written in the wrong patient's chart." So I called the ordering physician. "Oh, he had a CT scan at another hospital last month. The endocrinologist saw him there. They did some kind of work up there, I think." Seriously? I told him it was a waste of time to repeat the work up so he would have to get the information for me.

Recently, I was asked to see a patient for thyroid nodules. First of all, I fail to understand why a thyroid ultrasound was ordered in a patient with urosepsis. 

I know, that these are quick in-and-out consults that I can do in 20 minutes or less. I also know that I get paid just as much for these visits as I do for a patient with newly diagnosed diabetes who needs to start insulin. But it saddens me that this is the state of our healthcare system and am appalled by the waste of healthcare dollars.