The Art of Covering

I was a little taken aback when Dr. C. changed my patient from warfarin to one of the “Novel Anticoagulants”, and one I seldom use, at that.

I have only worked with her for about three years, and we seem to come from the same mold, seasoned family docs with a penchant for teaching and patient empowerment. I had not imagined she would step in and completely change my treatment plan when she was just covering for one day.

As far as which is safer, warfarin with variable therapeutic effect and fluctuating INRs or Novel Anticoagulants, which have hardly been studied at all in patients on dialysis, you won’t see test results that may worry you, but the unknowns are still there.

It was a judgment call, and she took it upon herself to change my treatment. She may never see that particular patient again, but that brief doctor-patient relationship has changed my patient’s risk of stroke, to the better or to the worse, I don’t know which way.

As we are now adding a couple of new providers to our clinic, I think back to discussions we had 20-25 years ago, when we had another major influx of providers.

We met back then to talk about what we all wanted from each other when “covering”, and we were all pretty clear that, even though we might feel tempted to tweak blood pressure medications, diabetic regimens or other things while treating an acute problem, we wouldn’t necessarily appreciate if someone did that to our patient and our treatment plan.

So we had a truce: We would deal with the problem at hand and suggest that the patient talk to their PCP about adjusting their treatment. As far as the acute situation, we agreed to emulate each other’s style a little. Dr. Z often gave very explicit advise on over the counter and alternative treatments for more or less self limited illnesses, while I have always been inclined to say, “those things won’t make this go away any faster, they just keep you busy while you wait”. I did a lot more handholding when I covered for Dr. Z. and I think she was less adamant about my patients spending money at the health food store.

Doctors aren’t all the same, and patients usually gravitate to providers who meet their needs. And, I hope this doesn’t surprise anybody, there are many different ways to treat the same problem. Trained “abroad” and old enough to have seen medical “facts” come and go, it has been obvious to me for a long time.

I think there is a balance here. A patient who seems dissatisfied with the status of their condition or its treatment deserves to hear that there are options, and a covering provider can point that out, but to offer such advise unsolicited can do more harm than good. We shouldn’t try to look smart at the expense of our colleagues. It may be better to approach that colleague privately and say, “do you still prefer warfarin over Xarelto in dialysis patients?”

I’m still thinking about that one.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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