a recipe for disaster

 

Bye-bye, summer.

 

 

I retired after thirty years in Family Medicine out of fear.

 

I didn’t leave because of the long hours, or the fact that I’d been running hopelessly behind schedule all day, every day for three decades. I didn’t leave to take an easier position or to make more money. I didn’t ask to be excused because of fatigue or forgetfulness or ill health.

 

What scared me was the inevitability that I would miss a critical diagnosis, and because of it, I would subject the patient to unnecessary and inappropriate testing and treatments...all because I didn't get the patient's full history. I didn't know the whole story. Who had time to listen? Who had time to search for physical clues to the diagnosis?

 

"I think of my patients as

body AND mind;

the more I understand about both of these,

the easier it is for me to help."

~Dr. McKenzie Mescon~

 

This fear reflected, in part, the trend toward productivity requirements that link complexity with compensation. Briefly...a doctor generates more money by seeing more complicated patients in less time and by utilizing fewer diagnostic resources in their care. This is a sure recipe for disaster.

 

Let's say a patient presents with a sore throat and fever. His health care provider checks his throat and ears, and feels around for swollen submandibular lymph nodes. A throat swab is negative for Strep. But because he's running behind schedule, and only has ten minutes to see the patient in the first place, the provider fails to palpate the enlarged supraclavicular node that would have tipped him off to the real diagnosis...the lymphoma that was simmering out of sight. The lymphoma that was causing the patient's night sweats, fatigue and weight loss that no one asked about. It has happened. 

 

"The important thing is

not to stop questioning.

Curiosity has its own reason

for existing."

~Albert Einstein~

 

Last week I told you about the mysterious case of frostbite that was only diagnosed after the provider went back and reviewed the whole story with the patient. Some time ago I related the history of a patient who claimed her left orbital blowout fracture was the result of a fall causing her to strike the corner of her TV...when in fact, it was the result of a blow from her boyfriend's fist that required me to secure a PFA and to find safe shelter for her. That took time, but it may have saved her life.

 

Isn't that what physician productivity is really all about? Time constraints, reimbursement issues, and productivity aside...we are here to deliver high quality, compassionate, and complete health care to our patients...not to play "stop the clock" with them.

jan

 

 

 

 

 

 

 

 





how to save time and money

 

"Why, certainly. Help yourself..."

 

This summer, I enjoyed a brief writing hiatus that included a week away at Kripalu Center for Yoga & Health for the third annual conference on Narrative Medicine. Of course, I came back ready to share what I learned about compassionate listening, cognitive coupling and dissonance, and the interpersonal neurobiology of storytelling...and how all of that relates to patient care and healing. No small task.

 

But it wasn't until I got home and was enjoying a cup of coffee with an old friend, a nurse practitioner, that the point was driven home. She presented me with this photo of a patient's foot and dared me to make the diagnosis:

 



 

This was the patient's history: She'd been seen in the emergency room several days earlier with an injury to the foot. She said she'd twisted it. X-rays were negative for fracture and she was discharged with instructions to elevate the foot and apply ice for pain and swelling. A few days later she saw my friend for follow-up because her foot had gotten so much worse. This is a picture of the foot at follow-up.

 

What do you think was going on?

 

"There is need of a method

for finding out the truth."

~Descartes~

 

I ran through a quick differential in my mind. Was it a crush injury? No. Necrotizing fasciitis from "flesh-eating bacteria"? No. Disseminated intravascular coagulation? No.

 

My friend, too, had been puzzled because the history did not fit the findings. So she'd gone back to the patient and asked again what had happened. If she hadn't taken the time and made the effort to uncover the whole story, she never would have made the correct diagnosis. The patient would have undergone expensive and unnecessary testing, and misguided attempts at treatment.

 

This is a case of frostbite.

 

To ice her foot, the patient had purchased an icing boot. It numbed her foot to the point that she left it on for 48 hours and didn't realize what was happening until she took it off. With this bit of additional history, the diagnosis presented itself. The patient underwent extensive treatment and rehab, and eventually recovered.

 

 "Listening constitutes the very

heart and soul of the

clinical encounter."

~Mary T. Shannon~

 

This is a perfect example of the importance of narrative in medicine. Taking the time to hear the patient's whole story promotes accurate, efficient, and effective evaluation and treatment. And, for all the CEOs and CFOs out there...that saves time and money.

jan