Where is the patient in patient care?

Robert Chang writes…

I was standing in the elevator with four other people, on call during my residency.  It was late but I had finally picked up my burger with fries on my third try to get down to the cafeteria without getting interrupted, so I was happy.  I started to grumble inwardly as the elevator slowed before my floor, my fries leaking heat as the door opened.  A patient was sitting in a wheelchair with a transporter at his back.  The elevator people waited but the wheelchair remained motionless outside.  Despite a growling stomach I forced myself to stick my hand out the door as it was closing and I asked, “Coming in?”  The transporter said, “Nope but thanks.”  Puzzled now, I said, “Plenty of space, we can make room…come on.”  I looked back at the other people in the giant elevator and they were looking at the transporter, who was looking back at them to see if they would move.  That ambiguous yet definite amount of time passed which made it clear that the people really didn’t want to move.  The transporter shrugged and smiled, “No biggie.  It’s ok, I get paid by the hour.”  The elevator people, transporter and I laughed, the door closed, and I went on to the conference room, able to eat dinner for once.

This past month, I found myself asking, “How did this patient end up on our service?”  I was looking up patients I would staff with my resident team later in the morning.  A woman in her late forties with multiple wounds that were chronic and unhealing was admitted to us.  The odd part of the story was that she was a family practice (FP) patient who was seen just last week in their clinic with recurrent non-compliance caring for a chronic wound.  FP holds onto their patients somewhat ferociously, often to the great relief of our resident services and hospitalist group.  Pondering, I went to rounds.  There, the mystery became clear.  After multiple fractious discussions with the patient, the patient was fired from FP due to frustration with her non-compliance, and therefore, she was admitted to medicine for recurrence of her wounds.  She had not changed her bandages for 1.5 months since her last discharge from FP and had returned to the ED with concern for wound infection.  She had fired the visiting nurses that were set-up to see her.  The odor from the wounds per my resident was overwhelming, requiring an N-95 TB mask to cut the stench in order to enter her room.   When I went in to see her, her wounds were covered with old stool, dirt and hundreds of strands of hair that matched hers.   Inquiring into why she didn’t care for her wounds better, she indicated that her husband, children, in-laws and visiting nurses all told her she should but she just…didn’t.

Two very different images of health care.  Most of us have seen the former case of “patient care”, where things are going on around the patient without involving the patient or being explained to the patient. Other overused, more direct examples are rampant – confused octogenarians being readmitted for hypotension from too much metoprolol; post-discharge tests floating around without follow-up showing some disastrous diagnosis; PCPs encountering patients 6 months post-discharge that were hospitalized for weeks in the ICU without communication upon release from the hospital; the list goes on.  We have also seen too much of the latter part of health care, where patients are not caring for themselves, whether the gentleman with CHF presenting after Thanksgiving dinner where they over-indulged; the alcoholic spewing vomit and explicatives restrainted to their gurney; or the end-stage cirrhotic woman needing weekly paracentesis because they do not take their spironolactone and lasix.

Direct, clear language that translates health care for patients and enables them to make wise decisions is essential.  Just as important is the development a system where patients are given responsibility for their self-care.  The most recent post from the President on the health-care budget discusses the reduction of waste, unnecessary test and services etc.  There is no mention of patient education and/or compliance issues, with the attendant social conundrums that we face every day.  Is the discussion on health care really about where the money is pushed around, or is it about putting the patient front and center?  And how do we get there?  More in my next post…but until then, would appreciate your thoughts on the contributions to the problems of health care, particularly where patient involvement is central.

N.B. Details of the cases were changed for privacy purposes.

1 Comment

  1. Jairy Hunter, MD, MBA, FHM on December 21, 2009 at 1:01 am

    Very insightful, Robert. While some patients are content to let healthcare happen to them, as your first patient (and I guess your second, as well), I went directly to pity for the second. For whatever reason, she’s inept and/or incapable of taking care of herself. This is a real problem in our country, these patients who can’t or won’t take care of themselves. I can’t say I’m uniformly compassionate when these types of patients are on my service, however. It’s a huge drain on our system not only financially, but in terms of resources, energy, and efficiency. How we as a civilized nation ultimately decide to care for them will say a lot about our society.

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