49. CASE: Reality Check?

A clerk and resident are frustrated after a morning of taking histories from and doing physical examinations of patients referred to the GI Clinic. As you (the attending clinic gastroenterologist) are going over the morning’s work with them, the clerk and resident complain that most of the patients seem to have less clinically significant symptoms and physical findings than were described by their attending family physicians in the referral notes to the clinic.

They start an argument (which looks to you like it’s on its third round) about whether it’s the patients or the referring physicians who are responsible. Adding to their frustration, the Department Head interrupted them just as the clerk was beginning with one patient – who she was already thinking might be the healthiest person she’d seen in her entire rotation – and insisted on doing the history and physical himself. The resident, who recently arrived from out of province, gets some local information from the clerk, who tells him the significance of that particular patient’s family name (major regular contributor to the Hospital Foundation).

The clerk thinks several of the morning’s problematic referrals came from the same family physician, and that there should be repercussions for that physician, e.g., putting his patients at the bottom of the waiting list, or calling him up to complain. The resident defends the referring physician and speculates that it’s the patients who are causing the problem.

You’re wondering how to get them to focus on something more productive and professional.

  • Should you communicate to them that practice in the real world is like this, and that they should get on to the next patient? Or is this a teachable moment in some way?
  • Is this a clinical practice issue or an ethics issue? 

Some Values and Ethics Issues to Consider

  • Resource allocation
  • Compliance with policies and procedures
  • Respect for professional integrity
  • Patient-provider relationships
  • Health care provider relationships
  • Honesty, trust and truth-telling
  • Professional boundaries

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