Not Nurse Ratched thinks the doctor had a point. “Our responsibil-ity is to the patient’s well-being,” she says. “It is not to her well-being if you continue to just treat her and roll your eyes at her. We’re making her sick by all this radiation and testing that she doesn’t need.”
Unfortunately, even if the ER staff were to acknowledge Anna’s psychological problems, she would never be accepted for admission to a psychiatric hospital. I found it was often the same with Sarah. A patient’s illness has to be considered by a psychiatrist or a psychiatric resident as far more severe than anxiety—think suicide or psychotic break—in order to qualify for admission to a psychiatric facility.
Knowing on some level that she has nowhere else to go, Anna goes to great lengths to manipulate her symptoms in order to stay in the ER, including making herself vomit to the point of getting dehydrated and even having a rapid heartbeat.
Anna reminds me of Donald, my serial patient with chest pain. Donald was a lonely widower. In his most lucid moments in the ER, he would speak of how much he missed his wife. The subject would frequently bring tears to his eyes. Still, no matter how many times I tried to help him see a connection between his sadness and his chest pain, he still kept coming back complaining of physical symptoms.
Whether they visit the ER where I work in Toronto, or one in Camden, the fundamental reason frequent flyers see us is that they can’t get the care they need someplace more suitable. Dr. Jeffrey Brenner says this points to a lack of primary care, the kind of medicine usually served up by family doctors, internists and nurse practitioners.
What Brenner is talking about is increasingly referred to as the medical home, sometimes referred to as a patient-centred medical home. It’s a team-based model of health-care delivery that provides continuous and comprehensive health care to patients with the goal of keeping them healthy and as far away from a hospital as possible. The leader of the team can be a physician, nurse practitioner or physician assistant.
Brenner says he thinks our health-care system reflects our values as a society. “I think that in the last fifty years, we got very wooed by major advances in medicine. When we turn on the TV and see hearts being transplanted, Siamese twins being separated, you know it’s almost magical.”
These apparent medical miracles created the sense that doctors can and will do anything to save a life. As the professionals acquired more knowledge and medical prowess, non-medical people came to feel inadequate to handle even minor illnesses and injuries themselves. No wonder people just go to the ER instead of trying to fix a problem themselves.
You don’t have to be a patient or a physician in North America to understand what Brenner is talking about. America is dealing with a chronic shortage of family doctors. Recently, the Annals of Family Medicine estimated that there are 210,000 primary care physicians in active practice, and the percentage of American physicians who do primary care has been shrinking. To meet the needs of the population, by 2025, the nation will require an additional 52,000.
The solution, says Brenner, is to provide frequent flyers with the care that’s missing. For Brenner, the first step was to take the health-care utilization data he gleaned from authorities in Camden to identify medical hotspots. Step two was to set up comprehensive health care for frequent flyers inside the hotspot.
“I can ride around the city and point to buildings and tell you how many people live in the building, how often they go the ER and hospital and why they go,” says Brenner. “We went into one of those buildings and we opened a two-exam-room office right there. So patients can come down the elevator and be seen right in the building. About 100 patients in the building are coming down and the use of the clinic is really beginning to accelerate.”
Step three in Brenner’s plan was to set up a computer system that identifies patients who go to the ER to try to prevent return visits. “We pick patients up from the ER. We go to their house within twenty-four hours of an ER or hospital visit. We go with them to their primary-care appointment and with them to any key specialty appointments. We do a lot of training and education. It’s a full-care coordination and management model.”
How do they pay for this? For now, Brenner’s group, Cooper University’s Institute for Urban Health, has received a grant of $2.7 million to support the work of the Camden Coalition of Healthcare Professionals. If Brenner is right, the $2.7 million paid up front will translate into tens of millions of dollars of savings in the next five years. If successful, Brenner will have the ammunition he needs to approach state and federal governments to do this on a much larger scale. He calls it bending the health-care cost curve.
Preliminary evidence suggests the idea works. Remember Dennis Manners, the Louisville man who visited the ER at University Hospital 337 times in less than two years? The hospital enrolled Manners in its innovative Population Health Management Complex Case Program, which is patterned on what Brenner is doing in Camden. The results? The Courier-Journal reports that in the first eight months after Manners entered the program, he went to the ER just three times—far, far fewer than before. The cost of curtailing Manners’s frequent visits: a paltry $6,000.
Half a continent away, Saskatoon’s Dr. Ryan Meili is using the same idea but taking a somewhat different approach. In 2005, Meili helped found Student Wellness Initiative Toward Community Health (SWITCH), a storefront clinic run by health-care students that meets the needs of would-be frequent flyers. It’s a block away from the ER at St. Paul’s Hospital, the place Meili and the students want their patients to avoid.
Aside from paid administrative support people, volunteer health-care students staff the clinic—among them budding physicians, physiotherapists, nurses, dietitians and social workers. The idea behind the clinic is quite different from ER and hospital medicine. In the ER, we diagnose and treat clinical problems and ignore the social factors that contribute to the problem. At SWITCH, they treat medical problems but then pivot to social factors—issues such as housing, nutrition, immunizations and employment.
The difference begins right in the waiting room. In the ER, we don’t like frequent flyers using the waiting room as a hangout. Unless it’s the coldest night of the year, we actively encourage them to leave the moment their medical issues have been addressed. Not so at SWITCH, where the waiting area is a warm, inviting place for frequent flyers to hang out all day long. It even provides meals.
“We want people to come and stay and stay connected,” says Meili. “At SWITCH, it’s not just come and stay, but bring your kids. We have child care here, so that people participating in the programming or seeing the clinical team can have their kids taken care of.”
Meili told me about a typical patient I’ll call Rachel. “She was really struggling with anxiety problems,” says Meili. “Lots of people would just stay in the waiting room and visit but she wanted to see the clinical team. So a medical student and a social work student went in and saw her first. They sat with this young woman, who shared her story and got a chance to tell them what she’d been struggling with. At the end of that visit, she started to cry and said she’d never had somebody listen to her in that depth. “I think this is a model that could really be expanded beyond a training centre like this to models of primary care.”
What Meili and Brenner are trying to accomplish is something Brenner calls disruptive change. “What we really need in health care right now are delivery-system game changers that dramatically lower costs. And disruptive innovation, by its very nature, disrupts people’s careers, disrupts their lives and fundamentally changes how you think about a problem.”
In 2012, the U.S. Centers for Medicare and Medicaid Services announced it would start withholding up to 1 percent of Medicare payments from hospitals with too many frequent flyers. The maximum penalty is slated to rise to 3 percent by the year 2014. In the first year alone, the federal government is expected to dock more than 2,000 hospitals across the nation an estimate
d $280 million in Medicare payments. Medicare assembled the list of hospitals by looking at the thirty-day hospital readmission rate for patients with pneumonia, heart attack and congestive heart failure.
If frequent flyers like these could land at one of Jeffrey Brenner’s clinics, they’d be better off. But in the absence of a program like Brenner’s, it’s far more likely that hospitals penalized for taking care of frequent flyers will give them an even chillier reception than they already receive.
Suffice it to say that in the absence of disruptive change, frequent flyers won’t be going away any time soon. There’s a weird thing about that. ER doctors like me are acculturated to dislike frequent flyers. The frustration we feel at their repeat visits can lead to potentially dangerous situations.
ER nurse Megen Duffy says, “Nobody really even makes an effort to be civil to these people. We’re not rude to them, but it concerns me because we no longer take anything they say seriously, and at some point they’re likely to be sick. Everybody actually has an emergency at some point in their lives and we might miss it because we see them so often with made-up complaints.”
I’ll never forget the last time I saw Donald. At the time, nothing seemed particularly special about that visit. As always, he came in with an anxious look in his eyes. He complained of pain in his chest and upper abdomen. It was quiet enough in the ER for me to sit with him while we waited for his heart tests to come back. I asked Donald about his wife. He spoke at length about her devotion to him and how he missed her.
Either he was grateful for some extra attention or perhaps it was something else. On this one occasion, when I told him that his heart tests were normal and bade him goodbye, he said something to me he’d never said before. “God bless you,” said Donald, calmer than he had been when he arrived. Then he turned and walked out of the ER through the sliding doors.
A week later, I heard that Donald was found dead in his bed at home. I don’t know if he perished from a heart attack that I missed, or if he died of a heart broken by the loneliness of widowhood. Instantly, his last words to me echoed in my mind. I had always felt disconnected from frequent flyers, a state of mind I suspect most of us who work in the ER have. Donald’s words changed that forever. Every time I think of the patients I secretly mocked and ridiculed, I feel ashamed.
To me, they are no longer frequent flyers—just people in the wrong place. And one day, if people like Jeff Brenner have their way, there will be a lot fewer of them.
11. Blocking and Turfing
I’ve introduced you to medical slang doctors use to describe patients a good many of us find undesirable—including GOMERs, Yellow Submarines and those with a bad case of status dramaticus. Those are examples of slang doctors and nurses share freely not just with trusted associates but with those who work on other teams—generalist and specialist alike. As a profession, doctors recognize that when it comes to difficult patients, they are the enemy and we—no matter what we specialize in—are on the same team.
Now I’m going to let you in on a different kind of medical argot—a form of slang that refers not to unwanted patients but to the things doctors do to avoid looking after them. This slang also describes the games doctors play to persuade colleagues to take undesirable patients off their hands. The trick is to manipulate the other doctors without acting or sounding manipulative. It’s tricky.
Before I introduce the slang, check out this made-up but otherwise very typical conversation I have from time to time in the ER (usually around 1 a.m.) with a resident in internal medicine, in which I try to refer to his service an 87-year-old woman I’ll call Mrs. Jones.
“Mrs. Jones has a history of hypertension, hypercholesterolemia and type 2 diabetes with associated chronic kidney disease,” I tell the resident. (She has high blood pressure and high cholesterol, in addition to diabetes and kidney disease.) “She developed flu-like symptoms two days ago, including a cough now productive of sputum. Her daughter brought her to the ER because she was complaining of shortness of breath. Mrs. Jones felt feverish at home but didn’t take her temperature. On physical examination, she is afebrile [without fever] with an oxygen saturation of 89 percent on room air, rising to 92 percent on three litres per minute of oxygen by nasal prongs. Her vitals are stable. On chest exam, she’s got crackles on the right side. The rest of her examination is unremarkable. The chest X-ray looks like there’s an early pneumonia on the right side. I’ve started her on intravenous moxifloxacin for the pneumonia.”
“It might be an early pneumonia,” the resident repeats my words with a note of skepticism. “What did the radiologist say?”
“The film hasn’t been read yet,” I reply.
“Do you mind asking the radiology resident to look at it?” the resident asks.
“I’m happy to ask the radiology resident to comment on the X-rays. But I’d still like you to see the patient.”
“Why do you think she needs to be admitted?”
“As I said, I think she has pneumonia. She needs admission because her oxygen saturation was low on room air and improved on supplemental oxygen. That’s why she’s short of breath.”
“What’s the d-dimer?” the resident asks. A d-dimer is a blood test that can help rule out a pulmonary embolus (we nickname it PE), a blood clot on the lungs.
“I didn’t order a d-dimer because I don’t think she has a PE,” I reply. “Mrs. Jones’s symptoms are clearly those of a pneumonia-like illness, not a blood clot.”
“What’s her creatinine?” he asks. A serum creatinine is an important blood test that helps measure a patient’s kidney function. The higher the serum creatinine level, the worse the kidney function.
“Her creatinine is 158,” I tell the resident. In Canada, creatinine levels are expressed in SI units (measurements based on a modern form of the metric system) as micromoles per litre. In the United States, Mrs. Jones’s creatinine would translate into a level of 1.79 milligrams per decilitre. Whichever units you prefer, Mrs. Jones had a creatinine level consistent with moderate kidney disease.
“Have you consulted nephrology?” the resident asks, referring to the specialty that deals with diseases of the kidney
“I don’t think that’s necessary at this time,” I reply. “As I said, Mrs. Jones has chronic kidney disease caused by type 2 diabetes. She doesn’t need dialysis. If you want to get a nephrology consult, be my guest.”
“Did you do a lactate?” the resident asks me. A serum lactate is a blood test whose results are elevated in patients with sepsis, a potentially life-threatening complication of pneumonia and other infections.
“I didn’t do a lactate because I don’t think Mrs. Jones has sepsis,” I reply, getting a bit impatient. “She has no fever and her vital signs are normal. If you want me to order a lactate, I’ll be happy to do so, but I’d still like you to see the patient.”
“If she has no fever, why can’t she go home?” the resident asks.
“As I said, her oxygen saturation is low and she needs supplemental oxygen, which she can’t get at home,” I reply. By now I’m resisting the urge to ask the resident how may hours of sleep he had last night.
“What was her troponin?” he asks. A troponin is a highly sensitive blood test that measures certain proteins in the blood; it’s ordered routinely to rule out a heart attack. Unfortunately, the troponin level is also elevated in patients with chronic kidney disease, like Mrs. Jones.
“Her troponin is 72 nanograms per litre,” I reply, knowing what’s coming next.
“That’s a high troponin,” notes the resident. “She could be having an ACS.” (ACS stands for acute coronary syndrome, or heart attack.)
“But she has chronic kidney disease,” I say. “That’s probably the reason she has a high troponin. Her electrocardiogram showed no signs of an ACS.”
“Still, that sounds more like a cardiology referral to me,” says the resident, who turns and
walks away.
I sigh. I’ve just spent ten minutes trying to sell a referral to an internal medicine resident young enough to be my son. I page the cardiology resident and repeat the story to her. By now, it is 3 a.m.
“Sounds like pneumonia to me,” says the cardiology resident. “I’m happy to see the patient, but with her chronic kidney disease, I think internal medicine should admit her.”
After I speak with the cardiology resident, I chat with the resident in internal medicine a second time.
“Why don’t you get a repeat troponin?” he asks. “If it’s not any higher than the first one, then I’ll be happy to see her.”
The second troponin level comes back from the lab at 6 a.m. I go back to see the internal medicine resident in a side room, where I find him seated with the other residents and students on his team.
“The second troponin is 70 nanograms per litre,” I tell him. The second troponin level is just a hair less than the first test result, confirming that the elevated troponin level is caused by Mrs. Jones’s kidney disease and not a heart attack. This is the proof the resident said he needed to accept Mrs. Jones onto his service. But that isn’t the way things turn out.
“Oh, too bad,” the resident says. “We’re just about to go on rounds with our attending physician. I’m afraid the consult will have to wait until the new team comes on at eight o’clock.”
As they say in tennis: Game, Set and Match. As I leave the room, I overhear one of the residents congratulate the team on blocking an admission. From the congratulatory tone, there is no thought whatsoever given to the fact that it will be another four hours until Mrs. Jones gets admitted to a bed, and her daughter—who has stayed up all night waiting to speak with the doctor who would be treating her mother—will finally be able to get some sleep.
The Secret Language of Doctors Page 22