Working in my hospital, the national
dumping referral center in Malaysia, making and receiving referrals are quite a norm. As a houseman, I don’t personally accept referrals, but I have to keep making them. Now that I work in A&E, I have no choice but to refer, refer and refer.
Why do we refer in the first place? We refer a patient when we can’t manage the case further. For example, we refer to surgeons for intraabdominal injury because you can’t expect an emergency physician to perform laparotomy. We refer to neurosurgery for intracranial bleeding. We refer ortho for irreducible fractures. Sometimes we refer to get a specialized-care beds for example we refer to Coronary Care Unit (CCU) for myocardial infractions, we refer ICU for intubated patients. The MOs in charge will always say their beds are full, but we have to refer anyway.
And sometimes we refer just because the MOs are afraid of medicolegal issues that may arise. This is the most annoying kind. In a tertiary hospital like mine, everybody is uptight, everybody wants to save their own arse. Almost every case needs referrals, although sometimes it is not even necessary because even a mediocre house officer like me knows how to manage it. Due to an overwhelming amount of referrals, some MOs become very apprehensive while taking referral calls. They become fierce tigers, shouting to the person who’s referring to them, due to the nonstop referrals.
Me, I don’t like to refer patients unless very necessary. But being a house officer, I have no choice but to comply to this annoying system that I am stuck into. Imagine, a gynecology MO wants me to refer a patient for a simple pneumonia. Come on, even med students know how to treat pneumonia! Ortho MOs referring medical for sepsis, only in my hospital. In other hospital, ortho MOs handle the sepsis. I hate most referring to surgery because they always want to know the FBC, ABG, RP, PT INR, CXR, AXR and all other investigations in the world. Come on, if it’s a clear cut intraabdominal injury with hypovolemic shock, why do you need a Hb for? If there’s a big fat abscess at the flank of that old lady, why do you need a white cell count for? Yes, you might need all that investigations later, but can’t you see the patients first before the results come back?
Sometimes I have to resort to lying to the MO I am referring to because I have to get them see my patients. Else, my work is considered unfinished. I can be considered as committing a malpractice for negligence, failure to refer.
There was one polytrauma case with intracranial bleed and long bone fracture, the patient was chest tubed and intubated. We refered neurosurgery as the primary team for the intracranial bleed and refered ortho for the long bone fracture. But I was scolded by SISTER (not a doctor) for not refering to surgery. Reason? I have to notify the surgeons when there’s a chest tube, in case the primary team wants to take the chest tube out. Come on! I am sure neurosurgery can take out the chest tube when they need to.
Seriously what kind of stupidity have I stepped into? Must every patient be refered? That’s why we see KL patients are very spoilt. Spoilt in sense of medical care, too many doctors from many specialties (sometimes unnecessary ones) treating one individual patient! In this case, patient care is fragmented and not unified. Spoilt also as in spoiled brat. Patients are manja demanding everything to doctors, sometimes even demanding to be referred when there’s no indication for referral.
My MO who worked in Sabah before transferred to KL, feels very stressed and depressed, because in KL he can’t treat his own patients. He said that he becomes like a postman, writing referrals and send patients off to the specialist clinic.
Although I am glad that I learn a few things or two referring patients, I feel that I am not doing any active treatment for the patients. I’d gladly get out of this hospital to go somewhere with less specialties so that I can treat patients on my own. I am not saying I am very clever to treat all kinds of patients, but at some point, I really have to start learning how to treat them. I have to quit being a spoiled-brat doctor who must refer every patients I see.
If I’m kicked out to Borneo’s district hospitals, I really need to manage patients on my own, rather than referring and referring.