Patient Stuck in Endless ‘Clearance’ Referral Pattern, Hasn’t Had Surgery in 6 Years

Mr. Smith, a 67-year-old man with a fair number of medical problems, has been trying to be medically cleared for an inguinal hernia operation for 6 years now.

It all started when he was seen by his primary care doctor and referred to a surgeon for a likely hernia. “It was a moderate sized hernia,” said his surgeon Dr Hollin Dere, “and after we talked about his medical history, I told him he would need medical clearance before we proceeded.”

After going back to his primary care doctor for clearance, the PCP sent him to cardiology, given his history of 1 cardiac stent. Cardiology wanted an echo, and when this revealed evidence of right sided hypertension, he was referred to pulmonology. When pulmonology saw him and did pulmonary function studies and a CT scan, a few small pulmonary emboli were noted, and a referral to hematology was in order.

In addition to that, he had a 1cm pulmonary nodule and was referred to cardiothoracic surgery, who wanted a referral to interventional radiology for a CT-guided biopsy for this peripheral lesion. Upon workup at the heme/onc clinic, anemia was noted and the patient was found to be hemoccult positive.

He was referred to gastroenterology for endoscopy, and on endoscopy he was noted to have gastritis and a small ulcer as well as many polyps in his colon, for which colorectal surgery was engaged. Upon close examination of the anus, unusual nodules were noted and dermatology was engaged, who also found evidence of chronic infection of his arm, prompting an infectious disease consult.

“As a rule of thumb” the PCP noted, “The number of acronyms on patients medical record is directly associated with length of the preoperative clearance process, and Mr Smith has a whole lot of acronyms!”

The patient couldn’t be reached for comment, as he was too busy shopping for a wheelbarrow into which he could fit his enlarging inguinal hernia.