I am a primary care doctor working in a quaternary care hospital. Primary care doctors see all sorts of undifferentiated patients and decide if they need referral to secondary care, i.e. a specialist such as a cardiologist or a neurologist. The specialist then determines if they need referral to tertiary care, i.e. a subspecialist such as a cardiac electrophysiologist or a neurologist specializing in movement disorders. Quaternary care is provided by a subspecialist of a subspecialist, who performs rare cutting edge medicine or surgery, such as gamma knife brain irradiation surgery for hard to reach brain tumors.
Working at a quaternary care hospital is a luxury and a burden. It is an obvious luxury in that I can usually get any patient the care they need relatively easily. It is a burden as it is sometimes cumbersome to actually identify the proper service to take on the care of the patient with so many different routes to go. Does the patient with the brain tumor go to neurosurgery or neurology or oncology or general medicine if a definitive diagnosis has not yet been established?
I am also a secondary care doctor. I am the doctor that office-based primary care doctors refer their patients to when the problems cannot be safely managed in an office setting; things like chest pain, severe infections, lacerations, and potential surgical conditions like appendicitis.
I am also a tertiary care doctor to other ER docs in other hospitals when their patients need more than the secondary care that their hospitals can provide. This is another burden of working at a quaternary care hospital. On a daily basis I am besieged with calls from other ER docs wanting to send their patients to my hospital. I field dozens of these calls every shift. The calls often disrupt my patient care and resident teaching and are generally resented by patients, residents and our staff, but they must be answered. My most remarkable referral until recently was a doctor in Israel who wanted to refer a patient to my hospital’s ER in Connecticut where I was working at the time. It was so far-fetched to me that I actually agreed that if he could get the patient here we would of course see him in the ER.
Two days later I got a call from one of my partners to come down and see “my” patient, newly arrived from Israel with a litany of long standing non-emergent symptoms. I paid a social call but left his disposition to the docs on duty, who promptly discharged him.
These transfer requests do give me a unique insight into the patchwork quilt of the U.S. healthcare system and its challenges but also its incredible strength and potential, just like America itself.
I was idly reading through the stack of referrals my colleagues had accepted on a recent shift when one caught my eye. The patient was coming to my ER from Syria to get a needed procedure. Not the town of Syria in Virginia but Syria itself via a refugee camp in Turkey. I sought out my colleague who just shrugged his shoulders and said it had all been arranged and he had been told to accept the patient. What the heck? This was not the mission of the ER.
I guess word of my discontent filtered upstairs because the Chief of the hospital paid me a visit accompanied by a social worker. They explained that the International Rescue Committee (IRC) had contacted UVA’s Family Medicine Refugee clinic about this patient and had crafted a plan over several days to get the patient here from Turkey to get the life-saving care he needed. As a refugee he qualified for emergency Medicaid insurance on arrival and so not only would his medical care be provided, but it would be paid for. That was not really my concern but I did think it was kind of cool that such a law existed.
As I thought about it more and more I became enamored with being part of this extraordinary demonstration of America’s wealth and generosity and decency, not to mention the logistical forethought that had gone into this transfer. The IRC had arranged for housing for the patient and his family in Charlottesville and going forward he would receive his care from the Family Medicine Clinic and our subspecialists.
I met the patient and his family in the ED, accompanied by an Arabic interpreter, an Iraqi who had served with U.S. forces in Iraq and had been resettled here after the war. The patient was quiet, the family humble and grateful, the interpreter patient and supportive. I welcomed them all to Charlottesville. This was met with weary, tentative smiles.
In this election year I know there is much to debate about America’s standing in the world and our policies toward immigration and refugees. But I have to tell you that caring for that patient felt like the right thing to do.