What we have here is a failure to communicate

My friend with the missing ascending colon (let's call him Ernie) has another problem. His father (Bert) recently had both knees replaced, and he had a tough time recovering from the surgery. He became delirious (he has some dementia), and he had a mysterious fever. They did a CT scan of his head to see if he might have had some new stroke damage (a small but distinct risk from surgery), and they did a chest scan to look for pneumonia.

Ernie was in the hospital room with his mother Phyllis while Bert was raving and trying to yank out his IVs. As might be expected, she was freaking out pretty well herself. A new kind of doctor -- a "hospitalist," who only takes care of people while they are in the joint -- came in. After wrestling with Bert for a while and finally shooting him up with enough Atavan to knock him into next week, the doctor told Ernie and Phyllis that the chest scan showed a lesion on his lung and lesions on his adrenals that looked like metastases. This information registered on Phyllis like a production of King Lear in Albanian. Ernie went down the hall with the hospitalist and they agreed that Phyllis was in no shape to digest this information. "There's no hurry," said doctor Incognito, "you can deal with it after things have settled down."

Ernie later mentioned this to his siblings. His brother called Phyllis, and she spoke with Bert's primary care doctor, who told her he'd looked at the scan and there was nothing to worry about. Ernie could tell from the way the story came back to him that the doctor was talking about the head scan only. How could an internist decide that the radiologist's report was wrong anyway? Finally, at his sister's urging, Ernie called the doctor. Thanks to HIPAA (see my post of July, 2006, in other words I'll get around to it eventually), the doctor didn't call Ernie back, but called Phyllis, who called Ernie to ask why he'd called the doctor, and Ernie told her, who called the doctor again, who finally called Ernie. The doctor had never heard of the chest scan before, but he had immediately accessed the radiologist's report over the Internet (and believe it or not, the radiologist had been in Australia in the first place!) and now he was, in technical terminology, ape shit. He had already scheduled a PET scan and a visit with an oncologist. He was mostly concerned with figuring out who to blame so he wouldn't get sued.

We still don't know whether Bert has metastatic lung cancer, or whether the two months delay in finding it would have made any difference at all. But we do know that failure to get information from point A to point B is a very common problem in medicine and an important cause of medical errors. Despite the movement toward managed care and the important role of the primary care physician in coordinating services, the medical system is inexorably growing more fragmented as technical specialization increases. In the old system, doctors had "admitting privileges" in hospitals and attended their own patients there. No more. And oh yeah, your radiologist is in Australia -- unless you're in Australia, in which case she's probably in Yemen.