You Got To Know When to Holdem...Thoughts on Physician Quality

Yesterday my last patient of the day was a young man with a history of multiple surgeries and medical problems. He developed a fever over night to 102 and transient abdominal pain. By the time he saw me his pain was gone but his temperature was still elevated. Knowing this patient as I did, even with the benign exam, I sent him to the ER for a stat cat scan of the abdomen and pelvis and a straight cath (he had urinary retention) for urine. I called the ER Doc to give report before my patient arrived.

From the beginning I was harangued with negative commentary. The Physician shook me down. Why was I sending this patient? The exam was benign why did he need a cat scan. Etc...Etc. By the end of the conversation I simply told the ER Doc...Look, I know this patient..something is wrong. Do the scan!

Two hours later I get a call from the ER. The labs looked OK. He was dehydrated and had a urinary tract infection. His white count wasn't that high. They were going to send him out with antibiotics. So patiently I asked..so what did the scan show?

Of course they hadn't done it. Angrily the ER physician replied, it's going to be negative! Fine we'll do it anyway.

An hour later my cell phone rang. Holy shit....abscess, his temperature is 104. He is going to the operating room now.

And see this is the thing about medicine. Everyone wants to try to measure physician quality using all sorts of strange indicators. Things like blood sugar control, rate of preventative screening exams completed, patient satisfaction. But you see to me...those are all indicators that are highly patient dependent. Either they get them or they don't...often the physician has little to say about it.

In my mind what makes a good physician is a little bit more subtle. In the immortal words of Kenny Rogers:

You got to know when to hold'em, know when to fold'em
Know when to walk away and know when to run!