When You Know More Than the Physician
Last week I got the opportunity to work at one of the community hospitals. I normally work in a large teaching hospital so the differences are like night and day. One of my patients was a new CVA. I happened to be in the room working with the patient when the neurologist arrived. I couldn't leave because I had the patient sitting edge of bed and his balance was poor. The doc didn't give me time to lay the patient down and step out. I was shocked at what I heard.
The patient presented as an infarct. The neurologist said the imaging came back negative so he doubted the patient had a stroke. He went on to tell the patient's wife that there was no way of knowing what happened.
The patient was already anti-coagulated so nothing else could be done. It was possible the patient would have another stroke but he had no way of knowing. I nearly bit through my tongue. I work directly with the stroke docs on my unit so I'm familiar with the tests that are available and the indications for each of them. This patient needed some studies of his heart to figure out where the clot came from. Several ultrasound studies would have been able to demonstrate exactly what happened. I've had several patients with stroke-like symptoms but negative imaging who are referred to as syndrome patients and get the same work up.
To say I was floored is an understatement. I don't know if this doctor hasn't kept up with the literature or if he even knew this in the first place. I don't know why he didn't refer the patient to a different facility with a certified stroke center that could have finished the workup. There are several in Houston. The worst was the physician telling the obviously upset wife there was nothing else and no way of knowing. That was a blatant untruth.
Patients and family members enter a new universe when a stroke occurs. They depend upon their physicians to provide the best possible information. They trust their physicians to be current on the latest literature and evidence-based data. That wasn't the case here. Our second-year residents know more than this guy. When they don't know they ask someone else. This would be an awkward situation for any PT. Those of us who have specialties or worked a long time with a specific patient type learn a lot. Maybe if I had been at my normal facility I could have gone to someone and reported what I'd heard. Short of correcting the doctor in front of the patient there wasn't anything I could do. How do you tell a physician he's wrong? Even if I had said something he had no reason to listen to me. I was a PT he'd never seen before. How could I know anything?
The whole incident happened in the space of a few minutes. I had that long to come up with a positive way of asking about TEEs, EKGs and the INR without insulting the doctor. I couldn't do it. Maybe someone else could have. The best I could do was report it to my immediate supervisor who looked at me like I was speaking a foreign language. I doubt anything will be said or done. In the meantime I feel bad for the patient. With all the knowledge and skills I've accumulated I couldn't do enough for him.