As Serious as a Heart Attack

A knock on the exam room door interrupting a patient visit is usually one of two things, a call from another physician or a patient with chest pain. It wasn’t a doctor. It was about a longstanding patient in his 60’s who was having chest pain. I took the call expecting to speak with the patient but instead found myself talking to his wife, (he was playing the part of the stereotypical male and had refused to call me) she was calling from home worried about him. He was driving back from work with pressure in his chest and in a cold sweat.  The symptoms were so concerning that I was puzzled they were even calling me. “Tell him to pull over and dial 911,” was my firm advice.

A few minutes later another knock came. This time the patient was on the phone. He told me that the pain had resolved and he was feeling better. As the pain was gone and he was only minutes away I told him he could come to the office for an evaluation.

When he arrived I inquired further about the nature of his pain. “It isn't really pain,”he said, “it is a pressure, like I have to burp. When I burp I feel better.” He went on to tell me that he had experienced pain like this in the past and that he had been previously diagnosed with acid reflux. He was confident that it was not heart related. He was still pain free and he denied any exertional component to his pain so I thought he might be right. I ordered an electrocardiogram anyway.

I went in to see the next patient while the nurse hooked him up to the ECG machine. A few minutes later I had the report in my hands. There were some mild changes in the lateral leads, minor enough to be possibly normal but significant enough they could be associated with decreased blood flow to the heart. He was comfortable and still certain it was indigestion so I decided to compare the ECG to one done previously.

He reported having an ECG done prior to a previous surgery so I logged into the hospital system to search for the report. I couldn't log in! I found myself locked out of the system due to a password problem. I had the staff call the hospital support desk while I went back to the other patient. I had decided that if the ECG findings were different from the previous one I would need to send him to the emergency room. If the findings were not new I would treat him for indigestion and send him to the cardiologist.

Twenty minutes later I still couldn’t log into the hospital system and did not know what to do. I decided to search for his paper chart in the garage attached to my office to see if there was an ECG from several years earlier. I found the chart and opened it to the ECG section. There I found a very faded ECG. It was perfectly normal. The changes on his ECG were new. I realized it might be his heart after all.

I went back into the office to share the news with him. When I walked into the room he told me the pain was returning. I quickly gave him a dose of nitroglycerin and an aspirin and had my nurse call 911. Within minutes the medics were on the seen and loading him on to a gurney for the trip to the emergency room.

The next day I received the report from the hospital. The major artery to the left side of his heart had been 95% blocked. The cardiologist had performed an angiogram and placed a stent. Remarkably, he was already on his way home. As I read the report I was struck with how close he had come to having a heart attack. His insistence that it was indigestion could have easily resulted in a missed diagnosis.

His story reminded me of some fundamental medical truths-

1. Denial is a dangerous thing.
2. All chest pain is serious until proven otherwise
3. Never trust a computer when you need it.
4. Men, especially married men, are often stupid. (just ask their wives)

- Bart

Thanks for reading and sharing. A special thanks to those who subscribe to the blog (just click on the button to also have posts sent to your inbox)

Missing at the End of Life- Courage

I talk about death a lot, almost every day. With healthy patients I talk about the need for advance care planning and the need to prepare for the unexpected. One of my common questions is, “If you walked out of my office today, fell and hit your head and suffered brain damage, have you made it clear to others what your wishes would be?”

The answer is almost always, “No.”

I then talk about “advance directives,” legal instructions about how one would want to be treated if something happened and they were unable to speak for themselves. I typically hand the patient a Durable Power of Attorney form that includes a section in which patients can clearly state which essential functions they equate with an acceptable quality of life. I tell them, “If you and I went to a local nursing home and walked the halls, the chances are that we would eventually see someone who was so debilitated we would say, Don’t ever let me end up like that!” I say that if we were asked why we would not want to be in such a debilitated state we would say. “Because they can’t _________” and that we would fill in the blank with those functions we believed essential, such as the ability to communicate, recognize our family, feed ourselves and do personal hygiene. My description is usually met with nods of agreement, as I have learned that most people have a clear understanding of what an unacceptable quality of life would look like for them.

While there is near universal acceptance of the idea that life can reach a point where it should no longer be prolonged it is still only a fraction of patients who take the time to write their wishes down. Less than half of the patients with whom I have these conversations takes the time to fill out the forms I give. I do not know if it is due to denial, forgetfulness or laziness but  regardless of the motive, the result is the same. Most people have not clearly communicated their wishes regarding end of life decisions. When terminal events occur, too many families find themselves in the hospital discussing life and death decisions with a doctor they have just met. As these conversations are uncomfortable and difficult patients can and should make their wishes known.

Sadly, I have learned that even clearly communicating one’s wishes is not a guarantee that they will be honored. I once had a patient who was terminally ill and who had clearly stated her wishes regarding end of life care, so much so that she had completed paperwork instructing physicians and paramedics to never resuscitate her if she went into cardiopulmonary arrest. As clear as her wishes were, her family did not follow them when the time came. Fear and panic set in and those wishes were not communicated to the paramedics when they arrived. Against all of her known wishes she ended up on a breathing machine in the ICU.

Her case reminded me that it is not enough for physicians to discuss end of life issues with patients. We need to encourage patients to have discussions with their families as well. Frank discussions need to be held so that everyone knows exactly what they will do when the moment arises. Patients need to be certain that family members not only know their wishes but are committed to honoring them when the time comes.

Physicians need to do their part as well. We need to be committed to supporting our patient’s wishes and making sure they are honored. On too many occasions I have seen physicians continue treatment in order to appease the demands of unsupportive family members. The adage seems to be that dead patients don’t sue but their families can. At times some doctors are more interested in avoiding a lawsuit than they are in honoring a patient’s wishes.

It is easy to criticize doctors for continuing needless care but there is plenty of blame to go around. Hospital administrators and lawyers need to step and support physicians and make it easier for them to do the right thing. Efforts need to be made to change the culture of healthcare around the end of life. Death needs to be treated as a normal outcome of life. It cannot and should not be viewed as a sign of failure. The clearly stated priority for terminally ill patients needs to change from doing everything possible to prolong life to doing all we can to provide comfort and dignity at the end of life.

This change will require courage. Patients will need to have the courage to face their mortality and plan for the end of life. Families will need to have the courage to face their fears and to honor their loved ones. Physicians will need to have the courage to lead, even when the journey is difficult.

Bart

Thanks to all who read and comment. Special thanks to those who share posts with others and those who subscribe to the blog (you can to, just click on the button!)

A Cancer Diagnosis- Missed

It was cancer and I missed it. I not only missed it, I missed it badly. The thought of malignancy never entered my mind. He had come in a few months earlier complaining of pain along the lateral aspect of his thigh. He was tender over the iliotibial band so I diagnosed him with iliotibial band syndrome and sent him to a physical therapist. When he came in a few weeks later reporting improvement I was confident I had made the right call.

The improvement did not last and within the month he told me the pain had worsened. Perplexed, I referred him to an orthopedic surgeon. The orthopedist ordered an MRI of the area and the accurate diagnosis was made. He had a tumor in the muscle of his thigh and it was malignant.

I never saw the patient again. Our final contact was over the phone. He had called me to tell me he was firing me as his doctor and would be seeking care elsewhere. He was convinced that it was my fault the diagnosis had been delayed.

I told him I understood his anger and frustration and that I wished I had thought to order the MRI sooner. I explained that he was the first patient with muscle cancer I had ever encountered and that the diagnosis was rare. Because it was rare, muscle cancer was not something high on my list of possible causes. I told him that doctors typically start with common diagnoses and then move down the list, that if doctors began every course of treatment searching for the extremely rare serious condition they would not be good doctors. He was not satisfied with my explanation.

He was not the only patient to leave my practice over his diagnosis. His wife and a family friend joined in the exodus, convinced that I was a “bad” doctor. I grieved at their decision and wondered what I could have done differently.

The truth is there was nothing I could have done. I am a human being with all of the imperfections that come with it. Medicine is to broad and the body too complex for any one doctor to master it all. Perfection is impossible.

In spite of my years of education and hard work, each day I find myself facing the reality that I will miss things. I hate this reality and it is a source of intense fear and anxiety but it is inescapable. I will occasionally make mistakes. Like every working person in the world my only option is to do the best I can every day and hope for the best. When my best is not good enough I have not choice but to accept the outcome and rely on the grace of others. More importantly, I need to extend the same grace to others when they fall short. 

-Bart

Thanks for reading. Comments and questions are welcomed. Remember you can subscribe to the blog (click on the button), or follow me on Twitter @bartbarrettmd, to be notified of future posts.

Modern Medicine isn't Always Modern

7 days after falling off of his mountain bike he decided his shoulder injury was more than a bruise. He had significant pain and swelling over his collarbone so I ordered an x-ray. He walked in the next day with the images on a CD. My staff loaded the images and the fracture was readily apparent. While the fracture was obvious I was not certain about the treatment. I wondered if surgery was indicated.

I wanted a quick answer, so I took a picture of the image and texted it to my orthopedic surgeon colleague. The answer came back in minutes- the injury needed surgery. Two quick test messages and instead of waiting a few days for an answer the patient walked out of the office knowing immediately what was needed.

A few days later I received a call from the daughter of a patient with dementia. Her mom was not doing well. The daughter said she was more confused, unsteady on her feet and declining. As it was hard for her to bring her mom to the office she wondered if I could make a house call. My willingness to stop by the board and care where the patient lived was blunted by geography. The patient lived almost 20 minutes away. The 40 minute round trip was too far to go during a lunch hour. As the daughter had an iPhone I proposed a compromise. I suggested a FaceTime consult. Two days later I had a “face to face” conversation with the patient. She had improved slightly but was still unsteady in her gait. I ordered an in home physical therapy assessment and made arrangements to check on the patient the following week. The daughter was greatly relieved.

Another evening that week I received a text message from a patient. He had what appeared to be a blister on the surface of his eye and was wondering if he needed to go to the emergency room. I had him send me a photo and quickly made the diagnosis of chemosis, edema of the surface of the eye caused by an allergy. There was no reason for him to go to the emergency room for the problem and I promised to see him in the office the next morning. Two text messages taking less than a minute saved him a lot of time and expense.

Friday afternoon brought another text medicine diagnosis. A patient was smoking and wasn’t paying attention. Hot ashes fell from the tip of the cigarette and landed on her chest. The resulting burn was painful and she was worried about how to treat it. She called the office and the receptionist gave her the number to our office iPhone. Shortly thereafter I was looking at the photo and texting back treatment instructions.

Interactions such as these should represent the future of medicine. They are accurate, efficient, cost-effective and convenient. They are also incredibly rare, as very few physicians offer such services. One may wonder why these innovative services are not more commonly provided. The answer is simple. Doctors are rarely paid for them. Insurance reimbursement lags innovation and insurers have not figured out how to pay physicians for electronically delivered care.

The dominant insurance reimbursement model is based on office based services for in person care. Patients are weighed, vital signs are measured and the patient is questioned and examined and providers are compensated based on the complexity of the condition treated. Doctors typically charge $65-$85 dollars for simple office visits. Since most insurers do not pay for electronic consults physicians who provide such services are forced to either provide them for free or charge the patient directly. When insurers do pay for digital care they reimburse physicians only a fraction of a standard office visit. The predictable result- most patients choose to come to the office and pay a $20 co-payment instead of the full charges for an electronic visit, and most physicians choose to call a patient in to the office instead of providing discounted digital services.

What is overlooked by all is the hidden costs of the current system. If one takes into consideration travel and wait times, a 15 minute office visit can take 3-4 hours out of a patient’s work day. If the visit is done electronically, a 15 minute visit takes up only 15 minutes! For conditions such as the ones I described above, and for conversation based visits to treatconditions such as depression, migraines, hypertension and even diabetes there is often no reason for a patient to physically be in the office. The current system is incredibly wasteful.

As wasteful as it is change, if it is coming at all, is coming an incredibly slow pace. If the delivery of medical care is going to evolve it will require a concurrent evolution in the manner in which medical care is reimbursed. The traditional fee for service approach must change.

At present the best hope for change can be found in Health Maintenance Organizations which pay physicians monthly fees to care for the patients, regardless of setting. The HMO model, which is focused on outcomes, is more likely to be open to innovations in care delivery. Accountable Care Organizations, a new type of care delivery model that also focuses on outcomes, represent another possible source for promoting change. Even with new care models the impetus for change will ultimately come from patients. As more and more people become aware of the advantages digital care brings the demand is likely to increase.

Some may wonder, given the current state of affairs, how it is that I am able to provide digital care. I decided years ago that I wanted to be an innovator and to embrace change. Three years ago I began offering FaceTime and Skype visits to patients. I did so at no charge to HMO patients and at the price of my least expensive office visit to my fee for service patients. The response was initially slow but as co-payments have increased more and more patients are choosing the digital option for their care. For me, even though digital visits do not pay as much as standard office visits the personal rewards of knowing I am doing what is best for my patients has made it all worthwhile.

The future is coming, and I intend to be a part of it.

- Bart

Thanks for reading. Questions and comments are welcomed. Consider sharing this post with your friends and even your doctor! To receive future posts in your email, subscribe to the blog. I can also be followed on Twitter @bartbarrettmd

When does Serving Become Enabling?

Get a group of Family Doctors together to talk about improving patient outcomes, any outcome, and one question is certain to come up, “What is the patient’s responsibility?”

Doctors are measured against a number of standards. Each month I get reports on the percentage of my patients who have had colon cancer screening, mammograms and pap smears. For diabetic patients the list is extensive and includes blood pressure control, cholesterol medications, blood sugar control and whether or not the patient has been screened for kidney disease.

In my office, staff members review the reports and make phone calls and send out electronic reminders to encourage patients to get the necessary tests and treatments. Every time I look over the list of names and review the charts I see that regardless of the test or screening all of the patients have something in common. Every one of them has been previously told what the tests were and been given the necessary orders and referrals to get them done. They just haven’t bothered to do it.

It is a source of unending frustration for doctors. We went to school to be doctors, to care for disease and provide treatment to patients under our care. None of us signed up to be patient care reminder professionals. Yet that is what we are becoming. My medical group recently announced a new quality measure that illustrates the absurdity of it all. We are now being measured according to how consistently our patients pick up their prescriptions at the pharmacy. Telling a patient to take a medication daily and sending the prescription to the pharmacy is not enough. If they don’t pick up their refills consistently we are held responsible!

Too many patients do not prioritize their health and instead expect their doctor to pick up the slack. Several months ago a diabetic patient came to our office for an initial visit. We started a new blood pressure medication, ordered the appropriate lab work and asked the patient to return in a month. Four months later the patient returned. The blood work had not been done, so the order was sent again to the lab.

Two months later, 6 months after the initial visit, the patient called the office requesting a refill of his medications. I checked the chart and saw that the patient still had not been to the labs. Reluctantly I decided I needed a firmer response. I left a voice mail and sent an electronic message saying that we wanted to partner with him in the care of his diabetes but that he had failed to follow our recommendations in spite of repeated calls from our office. I told him I would refill his medications for 5 days to allow him time to get his blood work done and be seen in the office and that no additional refills would be given until he was seen.

Nine days later on a Saturday I received a page from the patient. He had been to the lab that morning but he was out of his medications and he wanted an urgent refill. I was unable to hide my frustration when I returned his call. I reminded him that I had told him that he had to get his labs done and be seen in the office but that he had failed to follow my advice.

“So you are going to deny a diabetic his medication?” was his angry reply. My reminder that his lack of medication was a result of his personal choices did not go over well. He started to argue with me and I wondered what to do. I finally decided to offer a compromise.

“I’ll give you three days of medications and see you in the office Tuesday morning,” I said. He begrudgingly agreed. Before hanging up the phone I shared with him a truth that I often share with similar patients saying, “You know, If I care more about your diabetes than you do, there is something wrong.”

What was wrong with this patient is what is wrong with many patients. For a multitude of reasons, many of them understandable, patients fail to take care of themselves and to follow recommendations. Twenty years ago they alone suffered the consequences of their poor decisions. What few of them understand is how their poor decisions impact the physicians providing their care and how these consequences put a strain on the doctor/patient relationship.

As a physician who is committed to providing the very best care for his patients I find myself frequently wondering if I am enabling instead of serving, if there is a point when going the extra mile is actually a disservice to my patients, and how to determine when that point has been reached.

Although I think this patient may have reached it…

-          Bart

Thanks for reading, and especially for sharing posts with others. If you subscribe to the blog posts will be delivered to your inbox. Or follow me on Twitter to be notified of new posts. Comments and Questions are welcomed!