“Dr. Sham, can I talk to you for a second?” It was my third time working with this young physician assistant. “I’m not sure who else to ask, but this just doesn’t feel right.” This is what I get for being the coolest attending, I guess.
“Sure, what’s up?”
“I’m not sure what to do.” She started shaking. “I was pulled into my director’s office at [the sister hospital]. You know him, right?” Oh, that’s why. I knew it couldn’t be the “cool” thing.
“You mean Kennedy?” She nodded. “Okay, Dr. Kennedy, great guy. What did he do?” I braced myself.
“Apparently, we are being told by corporate, and Dr. Kennedy told me to my face, that if a patient has a head bleed and needs a transfer for neurosurgery, for instance, to call our mothership hospital three hours away and find an accepting neurosurgeon. Then, and only then, approach the patient and tell them the diagnosis: ‘Hey, you have bleeding in your brain; we have to transfer you to Mothershiptown, and Dr. Corporation will be waiting to see you.’ I couldn’t believe my ears. I don’t think that’s right, Dr. Sham.”
I took a deep breath, proceeded to my soapbox, and unleashed a rant upon the universe on corporate bullshit and ethics and autonomy, and over my dead body will that ever happen on my watch. My physician assistant had the insight that my old buddy did not have. Autonomy is the ability to make a personal, uncoerced decision. It is the cornerstone of medical ethics. This demand was the very definition of unethical.
“He says they’ll be watching,” she insisted. “We might be fired if we don’t keep at least 50% of transfers within the system.”
According to this administrator, my friend, we’re supposed to leave patients unaware of their own diagnoses for as long as it takes to be accepted at places within our own healthcare organization for the financial benefit of the company. Places we know damn well no reasonable person would want to go. So instead we document a tome to make sure we don’t get in “trouble”:
“Patient considered our transfer plan and opted to go where they have previously had substantial amounts of subspecialty care…”—and send the patient to the hospital just thirty minutes away. Not a fricking three-hour drive. For the dying woman’s blind seventy-seven year old husband who will probably die trying. Shamelessly forcing us to play this game delays care. To transfer a critical patient two hours instead of thirty minutes? To arrange this tougher type of transport? Good luck EMS. I wondered how long until…
Fast forward a few weeks. A colleague who was grandfathered in, no doubt petrified by the current landscape of surplus, especially given two older docs who were recently “not renewed,” did what he was told to do. Gramma had a fall and brain bleed. Dr. Colleague called the mothership and the slo-mo process of transfer began. Three hours later he is informed that transport is no longer available, they were diverted elsewhere. Two minutes later her nurse told him his patient was not arousable. He placed an endotracheal tube. He tried to arrange transport to the closer hospital, the clear choice hospital. They were full. He found a neurosurgeon at a hospital an hour away. The ambulance was on the way to pick her up.
He signed out to me, “The patient in bed eleven is Mrs. Lee. Her blood pressure is 88/40. She doesn’t look good.” The plan was reviewed: get her the hell out the door, it was her only chance. No one here could save her.
She arrived there three hours after he called them, and was whisked to the operating room, where she died on the table. Then the mothership called. They found an ambulance for our dead patient. I couldn’t wait to tell my colleague. He was distraught over the delay as it was.
Lesson learned. To make sure this never happens to me, any case with a similar risk of mortality or a ticking clock—I document the patient refused my recommendation and make an appropriate transfer without delay. I don’t ask. To me, asking would be more unethical than writing down that I did in order to keep my job and I refuse to be the unethical puppet arm for a corporation’s billfold. Still, I feel paranoid about being fired for doing the right thing to give my patient the best chance.
Is this how it’s supposed to be? It wasn’t my partner's fault; it was the corporation’s fault. It’s greed’s fault. But because we take such extreme ownership of our patients and our practices, it’s easy to forget that and blame each other or ourselves. It is not our fault. We are victims of the bullies, too. Fuck corporations.
- S. Sham