Tuesday, September 19, 2006

Unnecessary Consultations

In When Day Care Calls, Part III, Dr. Flea is annoyed that a parent wants an orthopedic consult on the benign to-be-outgrown condition of metatarsus adductor (translation: one of the kid's legs turns funny), all because the Day Care Director suggests there is more to be done. Flea gives in and refers the patient, against his better judgement.

I'm left to wonder, why the distress?
Is Flea worried the orthopedic surgeon will think he's an idiot for referring?
Is Flea worried the orthopedic surgeon will find something he missed? (shame, lawsuits, you name it)
Is Flea worried about the needless waste of healthcare dollars? (He hates it when his patients go to the ER unnecessarily, hates it even more when the ER docs don't consult with him)
Is Flea worried about wasting the orthopod's time?
Is this an issue of control for Flea? Won't he look bad if the orthopedist says "You arrived just in time, it's so good you have that wonderful DayCare Director to look out for you!" Will he gloat when the orthopod says "The pediatrician is right, they're nothing to worry about and little darling will outgrow this soon; never ever listen to those Day Care directors!"

Flea seems to be upset that the Day Care Director would second guess him, would suggest a medical consult despite his reassurances and her lack of medical training, and he may be insulted that the parent won't take his word on it for what is right.

It seems to be the nature of the beast that patients wonder if they're getting the best care. Doctors-bashing is fun, and we're bombarded by the media with images of physicians who've missed the diagnosis, who are lazy, money-hungry, egotistical and owned by the pharmaceutical industry.

Psychiatry has its own issues with referrals for consultation. Most psychotropic medications --especially anti-depressant and anti-anxiety medications-- are prescribed by primary care doctors, not psychiatrists. And primary care docs worry that they'll insult a patient if they say "You Need A Psychiatrist." Plus, in issues related to mental health, everyone is their own Day Care Director: often psychiatric symptoms are the same as what we might call Normal Reactions or You'd-feel-this-way-too-if-you-experienced-what-I've-experienced. Some patients resist the idea that their symptoms warrant getting help, they come for help at the insistence of a relative, a friend, the Day Care Director. Others long for a diagnosis, an explanation that absolves them of responsibility and that might even be something easily cured. Add to this the fact that psychiatric illnesses often include a symptom called Impaired Insight-- the inability to accurately see oneself (--"Damn it, I wouldn't be so irritable if you weren't such a Jerk!!!) and outside informants, Day Care Directors in assorted forms, can add invaluable information to the treatment process.

In a moment of empathy with Flea, however, I will say I prefer it when the Day Care Director says, "Maybe you should consult with a psychiatrist and see if there's a problem here," rather than, "You need to see a psychiatrist to get 900 mg of Lithium and 15 mg of Zyprexa for your Bipoloar Disorder."