In Medicine, Good Peer Interaction Can Be Hard to Diagnose

I was recently asked to become part of a group at the hospital who is trying to improve patient outcomes by improving glycemic control. I knew it would entail even more work on top of my already busy schedule, but it is something I believe in. I have gone on my own unofficial crusades before with some improvement in how the nursing staff handles things from their end, but it is a more systemic problem. And one that goes back to the ordering physicians.

I have to share a couple of incidents that highlight this glaring lack of clinical judgment. My associate was doing rounds in the hospital and had been seeing a patient on the surgical service. The patient was on a rapid-acting insulin as ordered by our service. The surgeon, in his infinite (lack of) wisdom, had the nurse hold the rapid-acting insulin and give regular insulin instead. Even the nurse knew better. She informed the surgeon that there was an endocrinologist on board, but he insisted that he wanted regular insulin to be given because it works faster. Now, any resident I ever gave a lecture to should know that regular insulin takes at least half an hour to kick in, while the insulin analogs take five minutes. So half an hour after giving the regular insulin (i.e. before it had a chance to work), the surgeon had the nurse recheck the blood sugar, and (surprise) it was still high. So he had her give the patient more regular insulin. A few hours later, that patient was hypoglycemic.

Case number two: My colleague was seeing a very sick patient, and the surgeon was going to start TPN. My associate wanted to add insulin to the TPN, as is the standard of care. The surgeon wouldn’t “allow her” to do so. She explained that if the patient was going to get all that glucose IV, that he would need insulin IV. The surgeon said, “let the nutritionist decide.” What?!?! My colleague is a lot nicer than me. She let him have his way until it was clear from the patient’s blood sugars (which were way too high) that she was right and he was wrong. Both the surgeon and the patient are lucky I wasn’t the one doing rounds that week. I would have written a lovely detailed note about my recommendation, signed off and told Mr. Surgeon to stick his TPN where the sun don’t shine. I don’t claim to know all things medicine. That’s why I leave things outside my specialty to the people who know what they’re doing. I did a year of a surgical residency and I could perform an appendectomy in 20 minutes through a two-inch incision back in the day, but I wouldn’t push Mr. Surgeon out of the OR today so I could take over a case.

So how does one approach a peer, or more accurately, a group of peers, and try to get them to see the light? How does one get another professional to change his ways? How do you disseminate information? It’s not like it’s not out there. Do lectures work? How do you get busy private practitioners to a lecture? With food? With CME credits? With door prizes? Should you send memos out? We get so much paper, who has time to read it all? Do we punish the ones who perform poorly? If so, what punishment? And who will enforce it? And trust me, I’ve seen this same problem at other hospitals, so it’s not just us.

We’re going to give this a shot. I’m not sure just how. I’ll keep you updated.

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