Professionalism in Practice
Trying to do what's best
“Doctor Pierce, Doctor Pierce, call the operator.”
It was 1984, the year I entered private practice. I didn’t own a cell phone. My hospital didn’t have an electronic health record. There wasn’t instant internet access to medical guidelines like UpToDate. Decades later I would consider these items essential to my hospital work; but on that fateful day, these things were unimagined.
The operator’s urgent request was an overhead page, so-called because it was announced through the hospital’s overhead speakers. It was loud. You could hear it on every floor, in every patient room, even in the doctor’s lounge and in the bathrooms. Overhead pages were almost always initiated by another doctor. It was the quickest way to connect with a colleague. Requests from patients or nurses went through the answering service who contacted me via my pager. The overhead page meant another doctor was trying to reach me on this Saturday morning, almost certainly with an urgent problem.
My rounds had already been delayed by a patient with pneumonia that necessitated an early morning admission. I was irritated that I was getting a late start rounding on the 14 patients on my list. I didn’t need another urgent problem.
I picked up the phone at the nursing station and dialed “O.”
“Doctor Pierce,” I said.
“One moment please.” The operator completed the connection.
“Hello, Dr. Pierce, this is Dr. Bledsoe. I have a somewhat difficult problem this morning. I was hoping you can help me.”
Dr. Sarah Bledsoe was a senior physician in our community, well respected for her excellent patient care and even-handed leadership skills. She had been elected by her fellow physicians to be Chief-of-Staff at our small hospital, the first woman to hold that unpaid position. “A thankless job full of headaches,” one of my partners described it. I had met her once before at a hospital staff meeting. I was new to town, having recently moved my young family across the country to join a group of primary care internists as their junior partner. I was still finding my way and trying to fit in.
Despite the ominous prelude, I offered, “Of course, how can I help?”
Dr. Bledsoe spoke quickly. “One of the nursing homes sent a patient to the emergency room with severe hyperglycemia. Her blood sugar is over 1,000. She’s a patient of Dr. George. The nursing home was unsuccessful in getting in touch with him, so they finally sent her to the emergency room. The emergency room nurse has been paging him for over 4 hours. He hasn’t returned a call. It’s inexcusable that he’s unavailable, and we’ll deal with that later. But the patient needs a doctor right now, and I’m hoping that you would be willing to care for her.”
Our small emergency room was just that. A room, staffed only by a nurse, who contacted patients’ primary physicians for orders. There was no physician in the emergency room and no on-staff physician to handle situations like this. I would be it.
I wanted to imagine that Dr. Bledsoe called me because she thought I was well qualified to handle this challenging medical problem. But it was more likely that she called me because I was the newest member of the hospital physician staff.
I hesitated just a bit. Dr. George was an older physician with an acerbic demeanor. Caring for another physician’s patient without that physician’s permission was a no-no, a breach of professionalism. I had learned this during my residency, when consultants only participated in a patient’s care when invited by the primary physician, even when the consultant’s opinion might result in better care. It was the captain-of-the-ship doctrine, preeminent in those days. I reasoned that with Dr. George’s unavailability, Dr. Bledsoe was now captain and she was handing off to me. “Of course, Dr. Bledsoe, happy to help,” I answered.
Medically it was an interesting case. Mrs. Alvarez was an 88-year-old woman with advanced dementia who had been admitted to a nursing home six months previously. She had no relatives and no advance directive. She had gradually become less alert over several days, and then became unarousable. Lab testing at the nursing home revealed a blood glucose of 1,175, ten times the normal value. That’s what prompted all the excitement and an ambulance ride to the emergency room.
The diagnosis was easy: nonketotic hyperosmolar coma, necessitating admission to the intensive care unit. I quickly calculated her water, sodium and potassium deficits, decided on the proper fluids and electrolytes, and the proper time to start insulin. I knew the algorithm and the calculations by rote, but consulted the Washington Manual in my coat pocket just to double-check. Treatment was intellectually challenging, requiring frequent blood tests and adjustments of her fluids. I wished a medical student had been assigned to her case. It was time-consuming, but interesting and fun. And gratifyingly, within 36 hours, her blood glucose was normal, and she woke up in her usual confused state.
I had attempted to contact Dr. George several times over the weekend to no avail. It was now Monday morning when I called his office after rehearsing what I would say. He came to the phone with a gruff “Hello.”
“Dr. George,” I said, “I admitted Mrs. Alvarez, one of your patients, over the weekend with hyperosmolar nonketotic coma.”
I waited for a response. I expected he might ask me how it was that I came to care for one of his patients, or offer some explanation for his unavailability, or even ask how she was doing. But instead there was silence. Finally he spoke. “I’ll see her later today and transfer her back to her nursing home, where she’ll continue to languish. You know, sometimes it’s best to just let these old people die.”
I was stunned and wanted to shout, “It would be best if you’d be a real doctor and take care of your patients.”
Instead I said, “She’s in room 402,” and slammed down the phone. What a jerk, being unavailable for patient care, and expecting someone else to pick up the pieces.
Several months later the Credentials Committee sanctioned Dr. George for poor professionalism because of lack of availability. They placed him on probation, with a warning that should he be unavailable in the future, his hospital privileges would be suspended. In addition, they extended a formal thanks to me for providing care to his patient, a positive note added to my own credentials file.
Three decades later I had left private practice and was teaching at a medical school. I was asked to give a lecture on professionalism. Not that I was an expert, but I had grey hair, now a senior clinician. My junior colleagues hoped that I might have helpful insights because I had been practicing medicine for a long time.
I thought about that weekend long ago, when Dr. George had been unavailable to care for his patient. Though over 30 years had passed, anger still rose in my chest when recalling that event. The first biomedical principle is beneficence, doing what’s best for the patient. He had put his own needs above the needs of his patient and violated that principle, an egregious breach of professionalism. I recalled my initial feelings of inconvenience and irritation when Dr. Bledsoe asked me to fill the gap left by a colleague’s gross lapse of duty. But despite that, I felt satisfaction and happiness for providing her the beneficent care that another doctor failed to do.
Like all professions, medicine is self-policing. Society has granted it autonomy of practice and self-regulation in exchange for an expectation of altruism and trust. So how does that work out in practice? When doctors misbehave, other doctors are supposed to call them out, step in, fill the gap and provide discipline. That ultimately happened with Dr. George. He had been a bad doctor. I had stepped in to provide care for his abandoned patient. I had been a good doctor. A sharp contrast in professional behavior. I still feel that way.
But with the passage of time, some of these sharp edges get smoothed down and one becomes more circumspect. Looking back to that event long ago, I don’t condone Dr. George’s behavior, but I recalled his words, seemingly callous at the time, but now whispering difficult questions for that proud, hardworking and self-reliant young doctor, certain that he was doing the right thing.
Did I review the fact that life expectancy in nursing home patients with dementia is less than six months, and that my efforts probably gave Mrs. Alvarez just a few more months of life in a nursing home “where she’ll continue to languish?” Would it perhaps have been better to send her back to the nursing home and “just let her die” peacefully in familiar surroundings, rather than admit her to the ICU, a noisy, impersonal place, where she endured repeated painful venipunctures? Was I too focused on the numbers and the intellectual challenge that I failed to consider what was in her best interest? Did I do what was most beneficent? Did I practice with the best professionalism?
Author’s note: Except for my own, I changed the names of persons in this essay to protect confidentiality.
Questions like those are never easily answered, but I'm sure your consideration of them made you a better doctor.
Such a great example of the difference of doctors caring for people and ones just biding their time.