Anonymous Doctor

Happy New Year.

I celebrated by going to sleep at 10:00. Which means I just woke up, 6 and a half hours later, and I think trying to get that last 90 minutes of sleep is going to be a futile effort.

I've been trying to come up with some New Years resolutions, but they're not ready yet. I'm hoping for something more than "do a better job at this doctor thing" and "do a better job at this life thing". We'll see what happens.

My patients finished off the year by simultaneously going downhill all at once. We have one who seems to have acquired a nickname. "The Cadaver." As in, "how's the cadaver looking today?" His blood pressure spiked, so we called a cardiology consult. The doctor came to see him when none of us were in the room, so he went to the nurse's station to make sure this was the right patient, and this was his baseline status-- he said he was worried something had happened to him between the call and when he got there, because he couldn't imagine we were calling a consult on someone who looked like he was already dead. We were like, no, that's what he looks like, and he's looked like this for a week and he's still here. The cardiologist had no recommendations, and said next time if we could refer him the living instead, he would appreciate it.

Which brings me to a weird practice that goes on in the private hospital-- specialist consults.

The way it seems to work is that whichever resident or attending wants the patient to see a specialist just calls whichever specialist they want, there's no system, there's no process-- so if you're a smart gastroenterologist, you just need to befriend all of the residents, make sure you get your contact info in their phones, and you'll get all the referrals and make money. See, the specialists aren't on salary-- they get paid per patient, they get paid per consult. And the way they get new patients, at least at the beginning, is to get hospital referrals-- they see the patient in the hospital and then the patient comes back as an outpatient. If all the residents know cardiologist X, and haven't met cardiologist Y, cardiologist X will get every referral, because it's like cardiologist Y doesn't exist. He has an office down the hall, he would love to see patients-- but it's not about availability, or competence, or a particular sub-specialty, it's just about who the resident likes and wants to send business to.

It's kind of absurd. You could have two neurologists, one who's awesome with stroke patients and one who's awesome with movement disorders, but unless the resident knows that, knows both of them, and doesn't have anything against one of them, one of them might get all of the business. It puts pressure on the specialists to be oddly and extraordinarily polite to us-- they are economically incentivized to be friendly-- they need us to send them business.

But it shouldn't work this way. The specialist you get should be the one who can get there fastest, or the one who will best serve you, not the one who's friendliest with your resident.

It's like you have to be a schmoozer and a salesman besides just being a good doctor. And the potential for corruption is enormous-- if I'm a specialist, what if I tell the residents that I'll give them a kickback for every patient they send me, under the table. Because what's the difference to them, they just need the consult-- and this way they get the consult and I get the business. I'm sure there's a rule against this. There must be. But if no one enforces it, the potential for abuse is obvious.

I guess that's enough on my soapbox for this morning. Maybe 2010 will bring an end to illness and accidents, and then I can sleep more.