1) The residents here did the right thing. They should take no shaming or blame. They did the correct and professional thing.
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Hospitals and doctors have a duty to care for patients. Residents have an additional important duty, that is to learn. That is what the ACGME and "caps" are there for. To protect the education duty.
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2) Residents should not be accepting patients this way. Maybe other institutions are different but attendings (or Chief Residents acting as attendings) should only be accepting patients coming from outpatient clinic.
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Even now as an attending I am leery about direct admits who have not been seen my me or a colleague in my own clinic. They often show up not as sold. A patient dying within hours of being called to admit, should not have been a direct admit. They should have been sent to an ER.
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3) No one should be forced to care for someone they know personally. Its hard to get a full picture but it sounds like the writer, the patient, and the residents are all in the same academic institution. Residents should not be made to care for a colleague.
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I did this as a fellow. It was someone I knew before medicine. It was a choice, I was offered to have someone else see the patient. I learned a lot from the experience, but mostly that I wouldn't do it again.
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It's impossible to not intermingle your personal history with the patient from your duty to care. It clouds the experience for you, and by implication the patient. I know attending docs who will do this, but it should not be a part of
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4) The hospital and supervising attending are clearly at fault here. Teaching teams cap, but hospitals don't. It's almost absurd to think of them as the same. Was the hospital not accepting patients? That's a different story entirely.
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This scenario right here is why ultimately ERs are so necessary and shouldn't get grief about waiting-for-admit times or for "non-emergency" care. Care is what is inportant. EM docs are palliation experts. They are comfort experts.
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They can refer to hospice and palliative docs can go to EDs and start patients on the care they need. This patient should have been in an ER. They don't "love" being the person getting cancer patients end of life care, but they do it and well.
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5) A cancer patient shouldn't die this way, but importantly no one should die this way. This person was facing imminent death. If it was known from cancer (uncertain from the scenario) palliative care should have been involved.
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They can do amazing things quickly. Get a hospice bed at a SNF, arrange for transfer, get services at home... They know what they can do, and they can do it fast. But they have to be called.
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Sidebar, they should have been called WAY before this scenario.
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So in conclusion. There a lot of, as we say, learning opportunities here. But Residents are learners. They aren't in charge, they aren't experts, not everything is in their control. ACGME takes a lot of deserved hits, the admit caps really are one of their better decisions.
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If this scenario makes you angry, it should. But if you have a "back in my day" component to the anger, I would argue it's misplaced. Largely because you shouldn't have been made to do the things you did then either!
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Finally, please. If you patient needs admission and you are stymied, send them to the ED. Then call the ED to explain why. Then thank the ED for helping. Then if you are anxious, pop over to the ED to re-assure the patient. You, them, the ED team will feel better for it.
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There's one more here, that I was having trouble articulating. 6) There is a specific spin to this case, that this was an Very Important Patient and thus exceptions to rules should be made. IMHO, VIP Medicine is particularly dangerous.
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Taking care of VIPs often takes aim at established norms. "We wouldn't usually order this test but..." "I wouldn't normal call this consult bit..." "FYI, this patient is a VIP so..." all of these can lead down a bad path. That little *extra* thing done can cause harm.
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Much of medicine (and the world) relies on norms to guide us. There are clear harms to over testing. There are risks making exceptions. This is doubly true when the patient is reinforced as being more important than the person in the next bed.
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Everyone wants to be a special patient to their team. No one wants to be the person less important to the team than the person in the next room. That's a dangerous precedent to set.
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End of conversation
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