If you recognized the title of this post as the title of a rather questionable rap song, you are old (just like me). I have mentioned in previous posts that OtherDoc has finally agreed to share weekend call with me. The inordinate luxury of having 2 whole weekends free of the pager is well worth the 2 weekends of double the patient responsibility. I have come to realize, however, that OtherDoc's patient management is a bit different from my own. This leads to occasional patient care dilemmas.
OtherDoc has been practicing for nearly 15 years, and sees probably quadruple the patients that I see, he is board certified, and sticks to the standard of care in most cases. Sometimes, I think, he gets just a little too busy, and can neglect certain duties essential for transfer of care like writing notes in the chart. I come from an era in training where the threat of lawsuits lurk at every turn, and documentation is your very best friend. We were taught that the chart should be able to stand on its own. After being in solo practice for so long, I can see where you could let note writing fall by the wayside, since *you* know what you are going to do/what you have done/what you are concerned about, etc. I, on the other hand, cannot divine the true purpose for hospitalization/plan of care without some documentation. I'm also finding that OtherDoc doesn't get a chance to do a lot of patient education (as evidenced by multiple pages over simple questions this weekend), nor does he share his plan of care with his patients all that often. Such was the case with one of his pregnant patients in the hospital this weekend. As per usual, we did a quick sign out at the office on Friday, where he basically stated the patient was a "chronic hypertensive in for rule out pre-ecclampsia, oh, and her sugars are a little out of whack, too." I left check out with the impression that the patient was to have a 24 hour urine protein, and if her BP was controlled on her new medication regimen, she was to be discharged. Imagine my surprise when I pulled the patient's blood sugars for the last 2 days, 90% of which were over 200 (!) OtherDoc had written for low dose insulin the day prior, but did not tell the patient his reasoning, and therefore she was refusing the meds. I also found, after a little digging, that her 1 hour glucola value (taken last month!) was well over 200 and the baby was macrosomic with polyhydramnios. Woo hoo. Her blood pressure, ironically, was just fine on the meds she was taking.
I sat and had a long talk with the patient, who was (more than a little) in denial about her condition, about uncontrolled blood sugars and the effects on the baby. She still refused insulin, so we compromised and settled on a trial of Glyburide, with the caveat that if Glyburide did not control her glucose, we needed to proceed to insulin. I also had the dietician come in to teach the patient about carb counting and diet control. Her 24 hour urine protein was consistent with mild pre-ecclampsia, but she had not had a baseline 24 hour urine, and I have the feeling that she may have had some proteinuria prior to the pregnancy. In the end, it all got straightened out, but I feel as though I may have taken a different direction than OtherDoc was intending to take. I surely don't mean to question or undermine his management, because there are several correct ways to approach clinical problems. I'm just trying to do the best for the patient under the circumstances. I'm sure, if he desires, he can tweak the adjustments I made when he sees her next. If anything, this weekend has just reinforced how very important it is to document your plan of care, and to share that plan of care with your patients. The good news is that this weekend is nearly over, and I will then have the next two whole weekends off! O frabjous day!