One of the most popular television shows to come out of the late '50s was "To Tell the Truth." Three plausible-sounding individuals would describe their occupation or profession—all claiming to be that person—to a witty, well-known panel of four. After questioning the contestants, the panel would then guess which person was the real jobholder or professional. After the panel made its choice, the host of the show would forcibly proclaim, "Will the real . . . please stand up?" Often, to everyone's surprise and consternation, the panel guessed wrong. Witnessing the parade of consultants coming and going to the bedside of a critically ill patient in our intensive care unit, I was reminded of this show, or at least its punchline. I was led to coin a syndrome, not an uncommon condition in a tertiary care center, called multiconsultism. Of all of these knowledgeable specialists, each expert in his or her respective field, which one was the patient's real doctor? Picture the scenario. The patient is an unfortunate octogenarian, admitted from the nursing home where she has long resided, for fever and altered mental status. Seen first in the busy emergency department by a harried "ED doc," the patient is found to have atrial fibrillation and is hypotensive and febrile to 104°. She cannot speak; her family cannot be readily located. She is assigned to the panel internist on call and sent to the intensive care unit because her condition appears precarious. Without going into the details of the syndrome as it develops, let me sketch the general outline. Because the chest film had shown a bibasilar infiltrate, the pulmonologist is called to consult. Quick to follow on his heels is the infectious disease doctor. Because the urinary output is low and the BUN is high, enter the nephrologist. Because there is some question about the patient's mental status, the neurologist appears. Because of the atrial fibrillation, a cardiologist is called. Because the patient cannot swallow, a gastroenterologist is requested. For every problem there is a specialist and for every specialist there are more problems. Meanwhile, the anxious family has been located and now keeps vigil at the bedside, trying desperately to ascertain exactly what's wrong and who's doing what. Who's in charge? From each specialist comes a tidbit . . . lung, kidneys, heart, here a bit, there a bit, nowhere a whole picture. Time was when the doctor could diagnose and treat a pneumonia, hydrate the patient, and correct an arrhythmia. Multiconsultism has changed all that. It is much easier and less time-consuming to call the specialist and let him or her handle the problem than to delve into the complex process of treating several systems gone awry (and, in more ways than one, probably more remunerative). But hold your pens before you rush to your rebuttals, those of you who take umbrage at these observations. This essay's author is not unalterably against consultants. I am merely asking the real doctor to please stand up. By the real doctor I mean the physician who is indisputably and recognizably in charge, the doctor who tends the whole patient rather than just one of his organs, the doctor who can still manage the common ills that he or she has been trained to treat. There is little doubt that there is a surfeit of specialists in urban areas, where tertiary care is a common phenomenon. Tertiary care breeds specialists. Specialists nurture tertiary care. Somewhere along the line the system has become abused and transformed. For the primary physician, consultants have become almost a habit. Born of lack of time or fear of liability, the habit diffuses responsibility and dilutes authority. The syndrome begins insidiously but worsens as the ills of the patient linger, as ills of this nature are wont to do. What entitles me to critique this system? I am a former clinician (a surgeon) who after retirement has wandered into bioethics as a second "career." Bioethics in the hospital setting dwells chiefly on end-of-life issues that beset aged, demented, and terminally ill patients. In my bioethics consultations I search fruitlessly for a statement of goals and values, probable outcomes, and the burdens and benefits of treatment. More often than not, I find only learned dissertations on the kidney, lung, liver, and heart by a parade of consultants. It is multiconsultism in full bloom. The distraught family watches the specialists go by like ships that pass in the night. The kidney may be doing well while the heart is failing; the lungs may be better while the kidney is shutting down. Families naturally cling to tidbits of encouraging news about one organ while the rest are crashing. That is the time when the real doctor must assert his or her role. Like the host of the game show "To Tell the Truth," I am asking the real doctor to please stand up. Along with our learned specialists (whom I do not decry, but admire and respect), we still need that old-fashioned generalist called my doctor. Will he or she please stand up . . . and be recognized? A Piece of My Mind Section Editor: Roxanne K. Young, Associate Editor.
– American Medical Association
Published: Jan 1, 2003
Keywords: atrial fibrillation,lung,consultants,intensive care unit,heart,kidney,consultation,fever,communicable diseases,critical illness,blood urea nitrogen,infiltrates,pneumonia,chest x-ray,cardiac arrhythmia