Heartfelt with Dr Melissa Walton-ShirleyView all posts »
The four Cs of competitionDec 4, 2011 21:02 EST
I saw a funny silent Marty Feldman clip once. The hilarious bug-eyed comedian was an undertaker in a small town competing with a mortician who also ran a funeral parlor just across the street. Each morning, they greeted each other warmly as they passed on the busy main street flanked by restaurants and dry-goods stores. Swathed in long black coats and top hats, the two crept about the town oddly with shovels, ropes, and whatever tools necessary to promote their business. Apparently, times were hard, so occasionally, one would knock the other unconscious, slip him into a wooden box and hastily start the funeral only to discover the box was empty. Suddenly, a shovel would crack the other's head and down he would go into another waiting wooden box! The cat-and-mouse game automatically started again until one could catch the other off guard. That same dogged determination driven by stiff competition is pervasive in all walks of American industry, and unfortunately, on occasion it creeps into the practice of cardiology. The greatest majority of us act honorably and courteously, but this piece is for those who occasionally do not.
Case in point: An acquaintance recently evaluated his patient for noncardiac surgery and explained that the surgery was risky, but he was well medicated and his stress nuclear demonstrated minimal ischemia in a small segment. Unfortunately, the patient suffered cardiac complications perioperatively at another facility but was discharged home in stable condition. Instead of the original attending cardiologist being informed of the need to pursue a workup or that complications had even occurred, he found out only when records were requested and the patent's care was transferred to the cardiologist who attended the patient in the other town. Fortunately, the original attending took the initiative to contact the patient, who was very relieved to hear from him. The original cardiologist remarked that if that same patient had gone to one of the larger hospitals in a true tertiary center, there would never have been any issues with referral back into his practice. Hunger, however, can motivate strange behavior. I insist it is no excuse to ignore the four Cs of competition.
The first two Cs stand for: Continuity of Care: I can't stress enough the worth of 20 to 30 years of knowledge of a patient's habits, intolerances, personality traits, and strengths. It's sometimes difficult to translate those subtleties like preferences, quirks, or psychosocial issues that are often not reflected in the medical record. On the other hand, the implication of a lapse in continuity of care issues can be more blatant. A patient was on her way to the cath lab for chest pain one morning when her usual attending cardiologist stopped the nurse and said, "Wait a minute, that's my patient. Does the angiographer know she's been spiking fevers to 103 at home over the last week and has lung cancer and a recent normal stress nuclear that addressed her chest pain? To which the nurse replied, "Uh . . . I don't think so . . . I'll call." Needless to say, the cath was quickly canceled and she was referred back to her surgical oncologist for treatment.
The next two Cs stand for Common Courtesy: Bob Harrington's interview with Clyde Yancy on civility was excellent. Although it may be difficult to remain civil in extreme instances, every effort should be made to respect a long-term doctor-patient relationship. I've always made great effort to get patients referred to our facility back to their original cardiology-care providers. I believe that if one is too lazy to build one's practice by reputation and hard work, with all probability, one is too lazy to take care of the patients they catch in their net. Even when patients come for a second opinion, we should call the other physician, if the patient will allow it, to discuss the case. It's a bit uncomfortable at times, but it keeps the lines of communication open and it fosters good karma. On almost every occasion, I learn something that helps with patient care.
In this tough economic medical environment where things may heat up over time, if we mind the four Cs of competition, the focus of our work, our patients, will be served best. Continuity of Care and Common Courtesy together make good practice and are the essential of the most important C of all, one that is most essential to fulfilling our duties as a cardiac healthcare provider: Character.