A game of ping pong has become common in the practice of medicine: patients have become the balls; doctors are the players. Some patients I have seen and talked to recently demonstrate this game.
One patient has atrial fibrillation and heart failure. His wife called me and said that he was looking pale. He lives 300 miles away and sees a cardiologist near him. I spoke with this patient before he saw the cardiologist. He said he was feeling tired and weak. I was concerned about anemia and worsening heart failure. I asked them to mention this concern about anemia to the cardiologist. They did, but the cardiologist said that an evaluation of anemia should be done by their primary care doctor. He was the heart doctor, not the anemia doctor. Hence, he ping ponged them to another doctor.
When this patient saw his primary care doctor, he was found to have colon cancer.
Another patient, a woman in her 70s, went to see her primary care doctor. She had vaginal irritation and itch. She also went because she had received a notice that it was time for her "wellness" visit. A wellness visit is a check list that Medicare and the Affordable Care Act champion as real medical care: such things as "have you had a tetanus shot, do you smoke, do you drink, are you depressed, how is your sleep?" and so on. This bureaucratic approach to medical care might be of some benefit, but in many cases it is little more than a waste of time.
The primary care doctor who saw this patient followed the check list. She has been taught that that is her job. If she performs the check list, then she is a good doctor. She gave the patient a tetanus shot. But she did not examine the patient's vaginal area. She did not even make a presumptive diagnosis and treat her. She told the patient that she would need to see a gynecologist. So the patient left that doctor's office with an untreated infection in her vaginal area.
This patient tried to get an appointment with a gynecologist but could not get one for a month. She went to see another primary care doctor, one who took less of a bureaucratic approach to medicine. This doctor examined the patient. She found, as any competent doctor would have predicted, Candida vaginitis. It was severe. By that time, it had spread to her groin. She treated her correctly.
When I taught internal medicine, I would often tell the residents and medical students who were working with me that the only reason to get a consultation from a subspecialist was for a procedure or to give medications that we could not give. I explained that as internists we should be able to figure out all of the medical problems and treat them appropriately. I encouraged them not to play the call-a-consult game at the drop of a hat. But that brand of teaching was not done in many academic medical centers. Instead, the name of the game was to call consults. And the consultants quickly learned to get into the act and ping pong the patient back to the general internist for this or that.
Here is another issue with the ping pong approach. Once I saw a patient who had abdominal pain. He had seen a general internist and a gastroenterologist. They did not discover why he had abdominal pain. When it came time for the rectal examination I said to him, "I realize you have had this done by the other doctors and I'm sorry I have to do this again, but I am stubborn that way. I like to get the data for myself."
The patient said, "That's OK. They didn't do that examination." This patient had prostate cancer.
This example demonstrates how doctors assume that other doctors have done certain things, but in reality, those things were never done. This leads to patients falling through the cracks.
This ping pong trend needs to stop. Leaders in Medicare and the Affordable Care Act and in academic medicine need to stop focusing so much on bureaucratic guidelines and treat the person in front of them.
W. Robert Graham, MD, completed medical school and residency at UTHSC-Dallas (Parkland Hospital) and served as chief resident. Graham received a National Institutes of Health fellowship at the Salk Institute for oncogene research in 1985. He was a professor of medicine at Baylor College of Medicine from 1998 through 2016. In retirement, he enjoys writing and ranching.