Recently I had a patient encounter go differently than the way I wanted. The patient is fine now, and it was not the fault of myself or the patient or her parents. Rather the problem was with the physicians, and more specifically, the protocols of the health systems they work for. In short, the patient had an abnormal exam, abnormal vitals, and diagnostic studies that I had done in the office that all supported the suspected (and later confirmed) serious diagnosis and just how sick she was. It was clear to me that she needed admission to the hospital quickly. It was even clear to the physicians at the two health systems that I called to try to get her admitted that that was the level of care she needed based on the labs alone. But because they couldn’t see this information in their EMR system, they declined to admit her directly and instead directed that she should go to the local ER even though they would immediately transfer her once she was stabilized, which I had already ensured she was. The reasoning: that’s how we do things. And so, the patient sat in the local ER waiting room for nearly three hours before being seen and then quickly being transferred to a higher level of care facility. A direct admission by either of these facilities would have had her receiving care within an hour.

I’m sure every physician has a story or two, or a whole volume of stories, like this. We followed a protocol. We did what we’ve always done. We’ve got a study behind us to suggest it’s the best way of doing things. Is it really? Is it always? Is there an old way of doing things that was replaced by a new way, only to find that the old way just might have been better than we thought? Most importantly, do we stop to consider these questions?

In the case of my patient, it’s obvious that she was failed by a protocol. I understand there are legal and logistical issues that affect everything we do as physicians. Sure, there are review boards and performance improvement committees, but so often I’ve seen these groups replace one insufficient protocol with another. In the end, we typically know our patients best, especially in primary care. We are their advocates and can give a lot of insight to other physicians who may be helping with their care. But are we being listened to?

This can apply to community organizations that we are a part of, professional organizations, maybe even our own families. The point of this is not to recommend that we change how we do things or to keep things as they are. The point is that we need to think about what we are doing for our patients, our families, our organizations, and our communities, and make sure we are always working toward the correct goal.

And so, I ask you the next time you are faced with making a decision in any of these settings, do you stop and ask what are we DOing? What am I DOing?