The Foglight - Navigating Specialization in a Confusing Healthcare System
May 2024
Issue #11 May 2024
In This Issue: I share a real family's experience with multiple specialist physicians during an Emergency Department to highlight the challenges and benefits of medical specialization. These different physician perspectives each have value, yet together they can be confusing to patients and families.
One Patient, Three Opinions on Leaving the Emergency Department
Specialization is one of the great blessings of the modern medical era; in 1900, say, it would have been unthinkable that patients would have access to separate doctors for heart, kidney, skin, lungs, mental health, and so much more. With specialization comes increased knowledge and better treatments. At the same time, having a profusion of doctors—as opposed to one family doctor, or a family doctor and a general surgeon—can also lead to conflicting messages, and confusion.
Not long ago, I was hired by a family to help them with their father, who had been diagnosed with a neurologic illness. Glen had also developed intermittent bouts of orthostatic hypotension—when he changed positions, his blood pressure dropped, sometimes leading to syncope, or passing out. One day, he had three episodes of syncope, and during one of them, he fell. His wife, Laurie, alarmed, called me. After we talked it over, she decided to take him to the emergency room.
At the hospital, we spoke with the ER doctor. He said, “We don’t know what caused the fainting. His labs look okay, we’ll order some tests, but he will probably need to be admitted for a couple of days.” He thought he needed cardiac monitoring to make sure the syncope wasn’t from a heart problem.
Next, the hospitalist showed up. She looked at Glen, read the same test results, and told the family that she agreed; he had to be admitted to the hospital for heart monitoring. She also wanted to adjust Glen’s medications—his medications for Parkinson’s as well as his heart meds—in a supervised setting. I didn’t talk with the hospitalist, but Laurie called me after she left. Laurie was upset. The hospitalist didn’t know Glen’s outpatient cardiologist and seemed uninterested in learning more. Laurie described the hospitalist as “dull.”
But then the cardiologist on call came by, a third type of doctor looking at the same issue from a different perspective. He reached a different conclusion. “I don’t think this is from the heart,” he said. “You could either stay overnight or go home now, but I don’t see much reason to keep you.” He suggested we work with the outpatient cardiologist to get the (previously recommended) loop recorder implanted. Unlike a Zio patch or a Holter monitor, a loop recorder can track a person’s heart rate and rhythm over weeks or months, not days.
Glen and Laurie had already been there all day, stuck in an increasingly busy, uncomfortable urban Emergency Department on a Saturday. We talked it over. Glen and Laurie weighed their options and decided to follow the cardiologist’s advice and go home. Their next step was to check out.
When the hospitalist heard this, she became upset and said she’d only release Glen “against medical advice,” or “AMA.” The nurses gave Glen an AMA form to sign. This form is something of a black mark, usually seen in the record of a difficult or uncooperative patient; for example, a heroin addict might sign an AMA if he’s checking himself out of the hospital, against his doctor’s orders, so he can leave to get a fix. To force this man to sign an AMA when there was genuine disagreement about whether he needed to stay in the hospital (after all, his cardiologist said he could go home) was pretty extreme. And it freaked this family out.
At this point, Glen and Laurie, whose son had hired me to help them make sense of the medical system, asked for my opinion. I said, “Don’t sign the AMA form. You’ve gotten medical advice saying that you don’t need to stay. Talk to the nursing staff and tell them cardiology said you can go home and to please let the hospitalist know that too.” The hospitalist responded by re-appearing, telling them that even if they didn’t sign the form, she was going to record their departure as AMA.
So Glen and Laurie sat in a swirling, noisy ER until the wee hours of Sunday morning, waiting for a bed to become available. Laurie was so exhausted she couldn’t drive home; she simply slept for a few hours in the chair by Glen’s bedside.
Once he was officially admitted, Laurie remained uncomfortable with the hospitalist. She didn’t trust her and said that this hospitalist didn’t know Glen at all. It was Sunday, so they waited until Monday to talk to their neurologist—a fourth specialist—whom they knew and trusted. They refused to allow any changes in the medications until then.
At this point, the family was thoroughly confused, didn’t want to be in the hospital, and continued to be deeply mistrustful of the hospitalist, who had threatened the patient with an AMA. And we can draw several learnings from this episode.
The first learning is that even a well-meaning doctor can destroy a therapeutic relationship by not connecting and tuning into the values of the patient and their family. That, combined with being overly aggressive, didn’t work. Perhaps, if the hospitalist had not alienated Laurie and Glen with the threat of the AMA, they would have allowed her to make thoughtful adjustments to his medication, which could have benefited Glen immediately. Or maybe they were right to prevent her from touching his medications. It's hard to know. Fortunately, nothing showed up on the heart monitor, and he didn’t have any more fainting spells.
The second learning is that a group of doctors can each be right in their own way, but still seem to be contradicting each other. It’s like the old story where three blindfolded people are trying to describe an elephant: one feels the trunk, one feels the foot, and one feels the tail. Each describes what seems to be a different animal. The emergency doctor was focused on the immediate problem—syncope, passing out—but not the whole picture, which included the possible contribution of the neurologic illness or its related medications. The hospitalist had some good ideas but was too forceful in her approach and did not account for the family’s attachment to their doctors. The cardiologist was purely speaking from a cardiology perspective about whether or not he thought a heart problem was the cause of the “complaint,” i.e. the syncope.
Finally, it’s worth remembering that this is a problem born of good fortune. We have so many different kinds of doctors now, with different kinds of expertise. And that’s a good thing. But we should not be surprised when they talk past each other. This is why an outside perspective, such as the one offered by a hired medical advocate, can come in handy.
This story is drawn from a real client experience. The names have been changed.
Email me with your questions, comments, or subscription requests at gm@mymdadvisor.com. I’d love to hear from you.
Warmly,
Gerda Maissel, MD, BCPA
Dr. Gerda Maissel, Author
Dr. Maissel is a Board-Certified Physical Medicine and Rehabilitation physician and a Board-Certified Patient Advocate.