Two days ago, while managing the outpatient clinic, I came across a pleasant old lady referred from another department. Why am I being subtle? The referring department was Orthopedics. The patient has long-standing hypertension and diabetes, and she already has peripheral neuropathy. In other words, she has high blood pressure and high blood sugar, long enough to cause end-organ nerve damage. She does not have any sensation on both feet, extending beyond her ankles. No sensations of pain, heat, cold, pressure, nada.
She must have stubbed the toe of her left foot, because in August this year, her daughter noticed pus seeping from the toe. It was a bit dusky, but she could still move all her toes. She was seen in the emergency department, and was promptly referred to Orthopedics. The patient was discharged with a course of oral antibiotics. Unfortunately the story didn’t end there. Her daughter brought her to the emergency department a few times in subsequent months, and she was also seen at the outpatient clinic. She was last seen in November, where the attending doctor referred her to General Surgery to exclude peripheral vascular disease (blood vessel damage). Maybe they didn’t have a Doppler machine to hear the pulsations of the vessels, but they could have at least done some investigations, such as feeling for the peripheral pulses and taking the Ankle-Brachial Pulse Index.
That didn’t irk me. Something else pulled the trigger. I did the bedside examinations and verified that the patient did not suffer from peripheral vascular disease. The left foot, however, was warm and slightly swollen. I suspected cellulitis (a nasty infection that crosses tissue layers from the skin inward). I called the Medical Officer on-call, to refer the patient back to them for further management.
What did the doctor tell me? “The patient doesn’t need surgery, right? Refer her to Medical.”
I said, “You’re the primary care team. The patient needs further treatment, and you cannot push her around.”
“That’s our policy.”
“Fine.”
I hung up and promptly called the Medical Officer on-call for General Medicine. She was kind and accommodating, but was overwhelmed by referrals at that time. She asked me to send the patient to the Emergency Zone, so that the ED Medical Officer could refer her to her colleague. Yeah, a bit convoluted, but at least they were more than willing to attend to the patient.
Let me make it clear that in no way whatsoever I am dissing the Orthopedics department. This is not the first time something as screwed up as this has happened, and this will not be the last. I have even witnessed pervious colleagues from my own department doing this to patients.
I am far from perfect. I come late to work, and I usually leave a half-hour early. I take extended lunchtimes when I know my patients are stable. Every so often I’ll lose motivation, and when I’m dead tired from hectic call schedules and cases, I’ll get cranky as hell. I make mistakes, though in my defense, I try to learn from them. But I am saddened by the prevalence of apathy among my colleagues. When we first decide to pursue this line, most of us are aware of what we’re getting ourselves into. It’s not an easy occupation, and the pay—if one stays in the public health sector—is nothing to brag about. As a matter of fact, a majority of us develop an inferiority complex when we compare ourselves with our contemporaries in private sectors. Those of us in major centers have a huge patient load, and we tend to overexert. We wear ourselves thin.
I can understand if a colleague is overwhelmed and cannot cope with additional patients. But pushing patients elsewhere when they have the resources to treat them, that’s just wrong. When asked, the common response will be, “this is a public center. If a patient wants better treatment, they can go to private centers.”
This “government” excuse for apathy is so overused, it’s a cliché. Yes, we concentrate our resources on treatments and medications that patients receive next to free, so much so that we cannot afford more comfort for patients and their families. This doesn’t mean Medical staff cannot offer the best possible comfort possible. People come to clinics and hospitals because they are sick. They want to get better. A little comfort goes a long way in facilitating this. I’ve seen some of my closest colleagues, both doctors and nurses, sigh and complain about their work—I join them in complaining, sometimes—but when they attend to patients, they put their game face on. They are at their best when attending to patients’ needs. I have nothing but love and respect for these colleagues.
Everywhere in Malaysia people are complaining that there are too many new House Officers produced each year, and their quality is steadily declining. One House Officer for every 2 to 3 patients. When I was one, the ratio was one house officer for every ward (28 patients). Theoretically, patient care should be better nowadays, right? I’m on the fence with this. I’ve seen good House Officers, and I’ve seen bad ones. However, I’m not so concerned about the sheer number of House Officers. The apathy of existing Specialists and Medical Officers should be addressed first.
Is this the example we want to set for the younger generations?
