Leaving against medical advice
In medicine, patients who have been admitted to the hospital have an option to leave despite being deemed too ill to be discharged. We refer to these patients as leaving “against medical advice”, or AMA. Many times patients sign out AMA whenever they feel a desire to leave the hospital when work-up is still pending. I once had a patient who presented with symptoms suspicious for myocardial infarction, but had a flight to India several days later. He felt symptomatically better a day after presentation, and decided to leave to pack his bags even though we had not completed all of this cardiac tests. I had another patient who was admitted for a gastrointestinal bleed from ruptured esophageal varices. No sooner had I finished transfusing him 6 units of red cells did he demand to leave. This guy was a cocaine addict who needed another fix. These are the cases which disobeying medical advice could result in death.
Other cases are not as obvious. I had a young diabetic teenage patient who was admitted for drainage and antibiotic treatment of an infection neck abscess. He left AMA before bacterial cultures could be speciated. While he was unlikely to die from premature cessation of his antibiotics, he did not complete his treatment and risked developing a superinfection or worse, a superbug.
Interestingly enough, the one universal bond that I have noticed about AMA patients is that they were all cared for by a medical team. Not a surgical team. Not a gynecological team. You can argue that fewer surgical patients leave AMA simply because there are fewer surgical patients in the hospital, but I believe the explanation is simpler: surgery has more tangible results.
The argument that surgeons “do more” for their patients is not only stated by surgeons, but also perceived by patients. When I was a medical student, the surgical attendings considered themselves the “Physician +” because they are expected to manage their patients medically and surgically. Those students choosing to specialize in surgery crave the satisfaction of intervening in order to make the patient better. Patients admitted to the surgical service expect a tangible intervention, like removal of an organ or excision of a tumor. They are not likely to leave against the advice of the doctor. Even those surgical patients who are managed medically, such as the small bowel obstructions, almost never leave the hospital without a doctor’s blessing. They are in pain, they cannot eat, and they also know that there is still a possibility that they may be cut open.
Sadly, the same cannot be said about patients managed by internists. The diabetic in ketoacidosis will start feeling better when their anion gap is near closure, but we cannot send them home if their white count is sky high from an unidentified infection. The patient doesn’t see this. He feels better, and wants to go home. The HIV patient with cryptococcal meningitis feels great after I hit him with some narcotics and a dose of amphotericin. He thinks that all he needs are some painkillers. Think again. If he goes home after this, he will be as good as dead–the amphotericin will have just enough time to frag up some fungi in his system to trigger whatever is left of his immune system to go berserk and maybe put him into sepsis.
It is unfortunate that medicine is perceived in this manner, by doctors, patients, and even insurance companies. It is at times frustrating to practice medicine in the context of this disconnect; it feels as if doctors are broadcasting on a different frequency as everyone else. Policy needs to be revised. Policy is being revised. But in the meantime, we will have to wait it out.