If Hattie had but one flaw, it was that she held her doctors in too high esteem. It was not unusual for an eighty year old woman of her culture to want to please her cardiologist. So when her blood pressure came up a little high, she was too embarrassed to admit that she had forgotten to pick up the Toprol prescription and hadn't taken it in over a week. The cardiologist hemmed and hawed, he buried his head in the computer, and eventually prescribed Norvasc, a new blood pressure medication. What he didn't do was ask about whether she had regularly taken her pills. He also forgot to tell her that leg swelling is a side effect of the medication.
But Hattie wanted to be a good patient. She squinted her eyes tightly and bowed her torso respectfully.
So you want me to take both the Toprol and Norvasc?
The cardiologist shook his head vigorously in affirmation as he reached for the door knob. He looked back, half his body already out of the room, and asked if there was anything else. By the time Hattie tried to lift her voice to answer, he was long gone. The waiting room was full and surely he didn't have time to stay around for her.
The next week, Hattie arrived at her primary care doctor's office for a diabetes check. After arriving thirty minutes late, he reviewed her chart. Although he read the cardiologist's note, the eleven page novel was so dense that he missed the part about the new prescription. He spent the majority of the visit clicking away at his computer and making sure Hattie was up to date with her Hgb a1c and lipid monitoring. When he was about to zoom on to his next patient, she leaped up to catch his attention.
But the swelling in my feet, what is causing the swelling in my feet?
Befuddled by his computer, rushing to get to the next patient, and thoroughly annoyed by trying to address an issue other than diabetes, he sat back down and scratched his forehead. The blood pressure was low and the legs were indeed swollen. Under intense pressure, he quickly reasoned that this must be an exacerbation of her congestive heart failure. He looked up at the clock and then down at the patient. He didn't re-review Hattie's medications. He didn't get on the phone and call Hattie's cardiologist. These precautions would have taken too much time. Instead, he wrote her a prescription of Lasix (a diuretic which would lower her blood pressure further) and ordered an echocardiogram.
Two days later, Hattie showed up to the emergency room dizzy and short of breath after lifting heavy boxes in ninety degree weather. She was dehydrated and had low blood pressure.
This is exactly what would be expected to happen to an elderly woman who:
- Inappropriately was put on an extra blood pressure pill because her cardiologist was too busy to ask about whether she had taken her medications correctly.
- Inappropriately was diagnosed with congestive heart failure instead of Norvasc-induced lower extremity edema because her primary care physician failed to illicit the history of a new medication or call her cardiologist.
- Was exposed to high ambient temperatures.
And what happened in the emergency room? The ER doc read the history in the electronic medical record of congestive heart failure, examined the patient and saw the lower extremity edema and incorrectly gave Hattie IV diuretic.
It was only hours later, when the hospitalist sat down at Hattie's bedside, that the tale of her woes came clearly to light. He ordered IV hydration, stopped the Lasix and Norvasc, and restarted the Toprol the next day when her blood pressure came back up. Then he sent her home.
Now, you may read this diatribe and think that my point is to trumpet the benefits of hospitalists or talk about the terrible diagnostic abilities of outpatient physicians.
But what I really want to say is that good doctoring takes time and concentration.
Both are commodities of which most well-intentioned clinicians, caught in the dictates of our flawed health care system, no longer have the luxury.
This post originally appeared on Dr. Grumet's blog, In My Humble Opinion, September 2, 2013.