World class..

This is what can happen when a private practice surgeon refers a complicated colon cancer patient to a medical oncologist affiliated with a certain multinational, gigantic world-famous non-profit health care system.

Let's say the surgeon is asked to see a patient with a large bowel obstruction.  Perhaps the colonoscopy demonstrated a high grade constricting lesion in the distal sigmoid/upper rectum and the CT scan revealed a massive, locally infiltrating mass invading into the bladder and a possible liver lesion.  Perhaps the patient has lost 30 lbs recently and has noted foul smelling material in her urine.  The surgeon is concerned about diffuse tenderness on exam, possibly due to impending cecal ischemia.  He books the case for the OR and curbsides a med oncologist on treatment options.  Should I just divert?  Would there be a role for neoadjuvant chemoradiation?  Or best to just try and resect now with possible pelvic exenteration?  The med onc guy isn't too certain.  Whether there is liver involvement or carcinomatosis is key.  But no time to determine that now given presence of an acute abdomen.  He thinks the case ought to be presented to the tumor board and perhaps a multidisciplinarian consensus could emerge.  The surgeon thinks this seems reasonable.  He performs a laparoscopic diverting colostomy and places a mediport.  CT guided liver biopsy is scheduled as an outpatient.  She recovers from the surgery and is discharged home.  Her instructions are to follow up with a med oncologist from the world-famous healthcare conglomerate close to her house, in addition to seeing the surgeon. Arrangements are made for the case to be presented at next week's tumor board.  Patient's parting words to surgeon are: whatever you guys decide, I want you to do the surgery.  I trust you



Two weeks go by and the surgeon has not seen the patient in his office.  He doesn't see her name on any future appointment lists either.  No one answers the listed phone number.  His secretary tells him there is a Dr X on hold to discuss a patient.  Dr X is the original med onc guy he had curb-sided.  Dr X is energetically imperturbable and affable on the phone:

-Hey man, just wanted to give you an update on that one lady.
-OK.  Did you ever talk about her in the tumor board downtown? 
-Um yeah.  She actually just had surgery. 
-I'm sorry?
-Yeah, one of my colleagues saw her in the office.  At tumor board we agreed that if the liver mass was benign then surgery would be the initial move.

-She had surgery?
-Yeah, my colleague referred her to Dr Y. 
-That's nice to know
-I guess they had to do some sort of modified exenteration procedure, partial bladder resection, hysterectomy...
-Good to know.  Good to know that when I refer patients to you guys that I will never see them again. 
-Sorry man.  My colleague saw her.  He usually uses Dr Y for cases like that.   
-Yes.  Your colleague.  Thanks for the update.  I hope she does well. 

Click. 

These hypothetical situations can be rather discouraging....