If Hattie had one flaw, it was that she held her doctors in too high esteem. It was not unusual for an 80-year-old woman of her culture to want to please her cardiologist. So when her blood pressure was found to be a little high, she was too embarrassed to admit that she had forgotten to pick up the metoprolol from the pharmacy and hadn’t taken it in more than a week. The cardiologist then wrote a prescription for amlodipine, another blood pressure medication. However, he neglected to ask whether she had regularly taken her pills. He also neglected to tell her that leg swelling is an adverse effect of the medication
But Hattie wanted to be a good patient. She asked, “So you want me to take both medicines?
The cardiologist nodded his head vigorously in affirmation as he reached for the door knob. He looked back, half of his body already out of the room, and asked if there was anything else. By the time Hattie started 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 physician’s office for an assessment of her diabetes. After arriving 30 minutes late, he reviewed her chart. Although he read the cardiologist’s note, the chart 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 that Hattie was up to date with her glycated hemoglobin and lipid monitoring. When he was about to zoom on to his next patient, she jumped up to catch his attention, asking, “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. Her blood pressure was low and her 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 the patient’s medications. He didn’t call Hattie’s cardiologist. These precautions would have taken too much time. Instead he wrote a prescription for furosemide (a diuretic that would lower her blood pressure further) and ordered an echocardiogram.
Two days later, Hattie showed up to the emergency department dizzy and short of breath after lifting heavy boxes in 90-degree weather. She was dehydrated and had low blood pressure. This is exactly what would be expected to happen to an elderly woman who:
And what happened in the emergency department? The physician read the history of congestive heart failure in the electronic medical record, examined the patient and saw the lower extremity edema, and incorrectly administered intravenous 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 intravenous hydration, stopped the furosemide and amlodipine, and restarted the metoprolol 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 tout the benefits of hospitalists or talk about the terrible diagnostic abilities of outpatient physicians.
But what I really want to say is that practicing good medicine takes time and concentration. However, both are commodities that most well-intentioned clinicians caught in the dictates of our flawed healthcare system have in short supply.