The magical mystery land of community health

I don't make this stuff up!…but I do change identifying information.

Who’s to blame? August 11, 2009

Filed under: Uncategorized — lesbonurse @ 1:14 pm

Recently, the New York Times online published an article titled “Are Patients in Part to Blame When Doctors Miss the Diagnosis?”  The article discusses a problem they dub “process of care lapses,” which is essentially a slowing of the diagnostic process.  This ‘slowing’ can be due to a provider mistake (such as an inadequate exam) or a patient error (such as missing an important diagnostic test).  The article then asks how much responsibility the provider bears for illnesses that result from these process of care lapses.

It’s a good question.  If I’ve learned one thing from working in a community clinic, it’s that I can’t make the patients do anything.  I’ve also learned that managing follow up in a clinic with thousands of patients is really challenging, and not very efficient.  Here’s an example: a woman in her 60’s goes for her routine mammogram, and they find a small mass.  She gets a phone call about the results and is advised to go in for repeat views.  She does, and they confirm the size of the mass.  She is called again and scheduled for a stereotactic core biopsy  She misses the core biopsy appointment due to a family emergency, and does not reschedule.  Four months go by, during which she does not come to the clinic because she is not due for any routine health care.  She returns to the clinic for a blood pressure check, and to the horror of the doctor seeing her, we realize that she never had the core biopsy of her breast mass.  We scramble to reschedule the biopsy, calling the patient incessantly to make sure she goes.  It’s cancer.  We scramble to get her into the oncologist.  The patient’s HTN is uncontrolled.  We scramble to squeeze her in for urgent visits, tinkering with her BP meds in the week leading up to her lumpectomy.  She finally gets the lumpectomy 6 months after the original mammogram, and is currently undergoing treatment for breast cancer.

What happened?  Who do we point the finger at?  The patient, for no-showing an important diagnostic test and failing to call to reschedule?  The PCP, for not looking up the core biopsy results and finding that the patient had never gone?  The clinic, for not having some kind of flagging system that would have alerted us to the missed appointment?  All of the above?  In this case, I think having a system in place that would flag the PCP about the no-show would have been most helpful.  The PCP could have called the patient, who–while needing some encouragement–was willing to get the test done.

But how about this patient: A woman in her 40’s.  A single parent with inadequately treated bipolar disorder.  Insulin-dependent type 2 diabetes.  Her HgbA1c is consistently >10.  She rarely gets her medication refills when she runs out.  She has a very hard time motivating herself to use her insulin on a daily basis.  I see her a lot when she has a problem, like her recurrent cellulitis.  I never see her when the cellulitis has healed.  I have sent letters asking her to come to the clinic.  I have visited her in the hospital to remind her to come see me for her post-hospital-discharge appointment.  She never came.  She never called for refills.  Busy with other patients, I stopped trying to get her to come in.  I didn’t see her for a few months.  Then last week, I got a letter from a local surgeon.  My patient–a woman in her 40’s with Type 2 diabetes–just had her first amputation.  Sad.  Is anyone to blame?  Me, for not calling the patient again?  The patient, for not taking care of her own health?  The local mental health facilities, for not having the resources to hold her hand and make sure she shows for psychiatry appointments, and then for not being with her in her home to give her the medications?

I think “blame” is a harsh word to use.  We all have some responsibility when patient’s illnesses are missed or poorly managed.  This includes the patients, who do have the responsibility to call us when they miss an appointment, or to let us know when they run out of medication refills.  But the providers, as the most health-system-savvy of the bunch, have the responsibility to make the system as easy to navigate as possible.  So now that I’ve identified the problems, I’ll get right on that health-care system overhaul.  Should be easy, right?  ha.