Just finished my third admission (which makes five patients to see tomorrow), and should be going to bed in hopes of not getting paged again. But I’m too upset about this last incident; so I’ll try to unwind it here as fast as I can. (Details changed, of course.)

10pm: Senior admitting resident, Dr. M, gets a call from the ER attending, that he wants to admit a 2 year old boy with asthma. The boy is a patient of a private doctor, who has the arrangement that the house staff will admit at night, and the intern will follow the patient, and the private will sweep through in the morning to make sure the intern is attending to everything just so. So Dr. M hands me the patient. I go talk to dad, play with the little boy, who is happily sitting in a plastic truck, waving at me, playing with my stethoscope – and of course crying when I touch him. He has no previous history of asthma; his parents noticed difficulty breathing and audible wheezing this morning. He has been feeling better since getting a nebulizer in the ER. Listen to his lungs: I’m already terribly uncertain, because all my lung exams for the past five days have been being contradicted; partly through my lack of experience, and partly when the exam actually does change after I listen. To me, it sounds like increased breath sounds, maybe very soft inspiratory wheezing, all over, as far as I can tell through his crying.

While writing up the H&P, I check the chest xray report: left lower lobe pneumonia. Humph. He doesn’t have a fever; it was a pretty acute onset. But he doesn’t have a history of asthma; the xray report is pretty definitive, not even their usual hedging “clinical correlation recommended.” And even I can see what they’re talking about without too much imagination.

So I report to Dr. M. She shows me how to write up the admission orders, with an IV antibiotic, with plans to keep him for 1-2 days on iv, then switch to oral antibiotics and send him home. Then, she goes to see him. He doesn’t look that sick at all; he doesn’t cry for her, either. When she explains the plan to dad, he objects. He’s self-employed, and recently decided that it was better to save the $750/month he was spending on health insurance, and pay himself if anything happened. Now, reassured that the boy doesn’t have asthma (which isn’t exactly what we said, since he could have asthma brought on or worsened by the infection), he wants to cut his costs by taking him home right now on oral medication. He and Dr. M have a polite discussion back and forth. Her bottom line is simply to say, “That’s not possible. You have to stay overnight now.”

I kept quiet in the room; I do know better than to argue in front of patients. I don’t even suggest consulting the attending. But back in our workroom, I do suggest that the boy isn’t that sick, the oral antibiotic will really do just about as well as IV, so there’s no reason to burden the family’s finances unnecessarily. After all, this is how the free market is supposed to change medicine: rather than doing unnecessary interventions, let supply and demand adjust the pricing, and let patients choose what treatments are worth how much money. Perfect case in point.

But Dr. M explains that, since the ER attending sent the kid upstairs, she is forced to take his word for it that the kid was sick enough to deserve admission, even if he looks better now. Moreover, since she’s operating under the private attending’s name, she can’t just admit and discharge the child, without the attending ever seeing him. Of course, the father could take him out AMA. But she tells me almost pointblank that it would be irresponsible, not to say wrong, to suggest this to the father. Even though she’s just decided that since the father will want to leave as early as possible tomorrow, it will be pointless to start an IV, so she will admit the kid – and give him oral antibiotics.

After “suggesting” till the interns looked up from their work and start explaining the facts of life to me, I’ve reached the point of absolute rudeness/insubordination if I go any further, and have to shut up. The only reason I didn’t work myself into a real ethical dilemma – loyalty to patient or to Dr. M? – was that the father gave a very definite history of his breathing improving after the nebulizer in the ER. Therefore, there is a decent possibility that he has asthma as well as pneumonia; so if he goes home, he will get worse again in a few hours without the nebulizer, and be right back in; which would do no one any good.

Dr. M called, not the private, but the distantly related private who was covering for the first one. This doctor obviously refused to take any responsibility, and recommended keeping the patient overnight. On oral antibiotics.

So here we have the absolute failure of a system, built around the assumption that all the residents’ patients will be covered by Medicare, and we can charge the government for any wild test we want, and that the best way for the ER doctors (and also the house staff) to avoid getting sued is to admit at the drop of hat – and sometimes just at the wave of a hat. Everyone is happy, except for responsible, independent-minded folks like this father, who are penalized, not just through taxes, but through personal costs, for the irresponsibility in society.

I apologized to Dr. M and acknowledged that she was ultimately responsible for the patient, and she said, she’s equally upset about the situation, patient should not have been admitted, we now created useless work for her, and for the interns tomorrow.

So the question is: when I’m a resident, will I stand up to the attendings and refuse to admit patients? Do you think I can succeed in being labeled uncooperative and disruptive even before finishing residency? (This is how medical boards typically get rid of the maverick doctors in a hospital system who try to buck the established methods when they see problems hurting their patients. See AAPS, on my sidebar, for more; too tired to hyperlink!)

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