The Outside Provider

In medicine, the Outside Provider is a running joke. And the irony is, it used to be my joke, too.

It goes something like this:

A provider who works in a big academic center with all the specialties in the world to consult, all the available scanners and tests, and all the time of the day to solve each and every problem of a patient (we will call them the “Inside Provider”), gets a phone call from the transfer center. A provider from a much smaller hospital, or clinic, usually in very rural areas (enters the “Outside Provider”), is on the line, requesting that her patient be transferred to the Inside Provider for higher level care.

“Argh. The Outside Provider from the Outside Hospital again!” The Inside Provider would roll their eyes and whisper to his colleagues about how totally incompetent the Outside Provider is, while the Outside Provider thanks the Inside Providers profusely, trying to ignore the condescending tone transmitted through the phone line.

I used to be the Inside Provider. After all, I graduated from Dartmouth Medical School and completed residency at the Mayo Clinic Health Systems. All other providers were Outside Providers in the dark green castle and where doctors worn suits.

“Do you have a procalcitonin level?” I asked.

“…we can’t run procalcitonin levels…”

“What did the MRI show?”

“…we don’t have an MRI machine.”

The conversation would go on for a few minutes, with me “grilling” the Outside Provider, and the Outside Provider’s voice grew smaller with each question I darted at him.

At times, I wondered if the Outside Provider was even curious about what happened to the patient after he transferred them to me. I wished, sometimes, he would call me for an update. And I would tell him, revealing the truth I discovered about the patient to him, something he was not able to do.

As we say in Chinese, “Feng Shui comes around”. A country doctor serving a town of 8,500 people, I am the Outside Provider now.

“I need an X-ray on this baby”, I took the stethoscope out of my ears and wrapped it around my neck. “Daniella, the baby just needs some extra help with breathing, we will be taking her to the nursery, Ok?” I looked over to Daniella, who nodded at me while tears run down her cheeks. After pushing for almost 3 hours to deliver her first baby, Daniella was exhausted, and nothing would restore her brokenness more than holding her new baby.

I followed the baby’s cart out of the delivery room, somewhat defeated. After delivering the baby as the family doctor, my job was to take care of both mom and baby.

“Ok doc, here is the X-ray.” The radiology technician said, as I took my mask off to take a sip of water. Before I saw the actual image, I had an idea of what I was looking for: a broken clavicle. I heard something snap as the baby’s shoulder came out. It was what needed to happen for the 9 lbs baby to fit through the tight birth canal of a first time mother. But I was not ready for what else the X-ray showed.

“Oh no. There is a pneumo.” My heart sank for a second. A pneumothorax happens when there is a leakage of the lung, allowing air to escape from inside of the air pockets in the lungs into the chest cavity. While a small pneumo can heal without intervention, a big or enlarging one can push the heart into distress while compromising the airway. This is called a tension pneumothorax. And it is life threatening.
My baby’s pneumo was small in size, and the fracture of the clavicle subtle. Judging from how little oxygen the baby needed to maintain saturation, and good lung sounds on both sides of the chest, this was probably not a case of tension pneumo.

But there was something that worried me: the heart seemed to be pushed a little to the side. I am not a radiologist, and I mostly take care of healthy babies, so I haven’t seen a ton of baby X-rays. You might be just imagining it. I told myself. I desperately wanted the baby to be ok.

“Doctora, the radiologist is on the phone, he said it’s important.” The charge nurse handed me the phone.

“Hi this is Dr. Harrison, the radiologist. Am I speaking to Dr.Zha?”

“Yes. This is Dr. Zha.”

“Ok. There is a pneumothorax on the right side.” I knew that. “And a small non-displaced mid clavicular fracture on the same side.” I knew that, too. Tell me something I DON’T know. I thought for a brief second, then immediately regretted wishing that. I don’t want to be surprised by the radiologist. Nobody does.

“Well, I can’t say for sure. But this might be a tension pneumo with the mediastinum pushed to the left side.” THIS was what I was worried about. Although looking at the baby, I didn’t think this was the case. But if the radiologist was going to put “tension pneumothorax” in his report, I didn’t want to take a chance.

“You might want to tap the pneumo.” The radiologist said.

This was a prime example of what Inside Providers don’t understand about Outside Hospitals: he thought it would be so easy and reasonable for me to put a needle into this newborn’s chest and let out the air, problem solved. I am a country doctor. I don’t tap pneumothorax. Have I read about how to do it? Sure. Have I ever done one, or even seen one? Nope. Am I going to risk doing something I’ve never done before and causing more damage to a stable baby? Definitely not.

“Call the transfer center, I am shipping this baby.” After hanging up the phone, I announced.

Of course Daniella was crying when I told her the bad news. “She will most likely be fine. But I think she needs higher level care.” She nodded, her body shaking from the sob. I gave Daniella a tight hug, and stroked her hair. Then I left her to process things.

Returning to the nursing station, I gathered all the data and put together a timeline of the postnatal care, and prepared my presentation to the Inside Provider who will either accept or deny my request to transfer this baby, depending on how convinced he would be after my presentation on the phone. I needed to make a clear case, a strong case, as a good Outside Provider.

The phone rang, and the charge nurse picked up. “Dr. Hill is on the line, doctora. The neonatologist from XXX.” She said.

I ran to take over the phone, and took a deep breath.

I got this.

“Hi, Dr.Hill. Thank you for taking my call. I have a 2-hour-old baby girl born to a 22 year-old G1P1 mother at 40+5 weeks of gestational age, whom I am hoping to transfer due to respiratory distress secondary to a tension pneumothorax.” Nailed it!
I paused for a second to catch my breath, and to see if the Inside Provider had any questions. Usually, this was when the grilling started.

“Mmhmm.” He said. That’s all? Ok I will keep talking then.

I went on to give the rest of the report, periodically stopping to check if he was going to start ridiculing me, or to tell me to get some tests or scans I didn’t have here.

To my surprise, he never did. He let me finish the whole presentation.

“Ok. Would you be comfortable tapping the pneumothorax?” Dr. Hill asked.

“Um. No.”

Then there was a moment. I was searching for excuses in my head to explain why this was, but I found none. And perhaps he was waiting for me to explain myself, too. But of course, he didn’t get any.

Here we go, I thought, he is about to let me hear of my incompetency.

“Ok. Please give the baby an IV bonus and then start maintenance fluids. I will accept the transfer. Thank you Dr.Zha, we will take care of the baby.”

Then he hung up.

I was stunned. No, I was almost in tears. I thought it was my job to profusely thank him, and God knew I was prepared to do so. But instead, he thanked me! And, I didn’t get the 25 question darted at me, like I usually got?

“Was he mean?” The charge nurse asked me, observing my stunned face. As Outside Providers, we expect push-backs and rude Inside Providers, who give us a hard time for transferring patient. Like how I used to be. This was why she asked.

“Um. No. He was REALLY nice!”

“Wow.” We smiled at each other.

The next day, I called the Inside Hospital, requesting to speak to Dr. Hill’s team. I imagined he was busy. We all were. Me, as an Outside Provider and a country doctor, might even be busier. Because while the Inside Providers had clearly defined work hours and protected time to round, I didn’t. I rounded on patients and delivered babies IN ADDITION to my regular clinic hours. This meant I went to the hospital before I went to clinic, in between patients, during lunch hours, or on the weekends. And if I stayed up all night, I didn’t get the next day off. I still had to fulfill my clinic duties.

I didn’t get to speak to Dr. Hill. But I did get the nurse on his team, who was taking care of my patient at bedside.

“Hi, I am Dr. Zha. Baby Daniella is my patient. How is she is doing?” I asked.

The nurse seemed very surprised to hear from me. As I previously suspected, not many Outside Providers called the Inside Hospitals to ask about their transferred patients. At least I never received such as phone call when I was the Inside Provider. Now, it seemed clear to me that this was partially because how unwelcoming the Inside Provider often sounded on the phone.

“Oh. Yes. Hi. She is doing very well! Dr. Hill tapped the pneumo, and drained about 25cc of air. And baby girl is now off of O2. It looks like she could go home in the next couple of days!”

These words filled my heart with warmth and gratitude. My eyes watered, thinking about Daniella holding her baby’s little IV connected hand.

“Thank you!” I replied. For a moment I thought I would just stop there. But I needed to say more.

“Um. I just want to let you know, and please pass this on to Dr. Hill as well, I am very grateful for your team taking care of my patients.” That did it, I choked up.

The nurse on the phone sounded like she was getting emotional, too. “Of course, we are happy to help. Thank you for checking in with us.” I gave them my cell phone number, and asked them to call me if they wanted to communicate further.

For a moment, I forgot that I was the Outside Provider, who just spoke to the Inside team. I forgot that I was the resourceless country doctor, instead, I was just a concerned primary care doctor who called to check on her patient.

This reminded me of an ICU attending I worked with in residency, whose closing line, after accepting patients form the inpatient teams, was always “Yes. I am eager to help.”

Not surprisingly, when he was on service, the inpatient providers were also more likely to just walk into the ICU and check on their patients that they cared for. People felt comfortable working as a team.

My phone rang in a couple of days: an unrecognized number from the town where the Inside Hospital was.

“Dr. Zha? This is Stella working with Dr. Hill in the neonatology team in XXX hospital.”

“Oh! Yes. This is Dr. Zha.”

“Hi. Dr. Hill wanted me to let you know that your baby is doing very well. She is ready to be discharged today. Are you able to see them in your clinic for a follow up either tomorrow or the day after tomorrow?”

Stella’s question was, can I make time in my clinic to see Daniella’s baby, my own patient?

“Of course! I will have my team call Daniella to schedule them now.”

“Great! Thank you. We would appreciate that.” Said Stella.

“Well. I am eager to help.”

In medicine, we don’t just have running jokes about Outside Providers. We have jokes about everybody else. The doctors make fun of the physician assistants, other specialists make fun of primary care providers, to name a few. This shame culture of medicine traumatizes everyone, yet everyone is more than willing to pass it on to the next person. I am not proud of this, but I have done quite a bit of shaming, myself. But if we were completely vulnerable in our own introspection, it’s not hard to see that this thorny torch that has been handed down for generations in our sacred profession likely stems from a deep-rooted insecurity/inferiority: in order to enlarge ourselves, we must belittle others.

The truth is, nobody holds the truth in medicine. If the pandemic has taught us anything, it is that facts are nice, but far from conclusive. What muddies the water even more is that only some aspects of this unbeknown truth are available to either the Inside or the Outside Providers. Often, the muzzle doesn’t come together unless the two parties work together. And in order to work together, we must abandon this Inside vs Outside mentality.

As an Outside Provider who used to be an Inside Provider, I’d like to declare myself.

I am just A Provider. And so are you.

Whatever specialty we are of, location we work in, the best Provider, is the Provider who is Eager to Help.