Chapter 5 | Part 3: Knowing When to be Your Own Advocate

Christopher Graham

by Christopher Graham

Getting back to the nature of the patient experience in this reality, I must say I’m slightly mystified as to how people navigate the healthcare system without intimate, working knowledge of how it works and how things are done. I think it has been perhaps slightly easier for me to deal with all of this stuff because I know how it’s supposed to go down. I understood that once the CT looked as messed up as it did, and my labs were as off as they were, that we’d have to get to the bottom of what was going on, no matter where that led. I never questioned whether we should do the work-up, I knew it had to be done. No one had to explain to me, for example, why a fine needle aspiration sample was inadequate for the final diagnosis. No one had to tell me why we needed to look in my belly with cameras before the surgery. No one had to tell me how important it was to do things like get out of bed and walk, and to use my incentive spirometer after the surgery. They would tell me that they wanted to order study X and I’d just say, “okay.” What it was, and why we were doing it, was understood by both parties.

I also know enough to know when I need to advocate for myself, or question something that they want to order. There was one time that they wanted to order a radiology test to look at something, the details of which are unimportant. But the thing was, we weren’t going to change how we were approaching the problem based on the results of the test. It wasn’t going to help us make a management decision. It wasn’t going to change the plan, essentially. So I asked them what the point of it was, and when they couldn’t tell me, we just dropped the idea all together.

I’ve also been able to catch mistakes and not let them be carried forward. When I was discharged from the hospital the first time, for instance, they kind of had a major screw-up. One of the things you have to do when discharging someone is to look at the list of meds they were on before, look at what they’re getting in the hospital, and then reconcile those two things so the patient knows what meds to take. This is unoriginally called “medical reconciliation” or “med rec-ing.”

Well, the person who discharged me did a pretty terrible job of that. I was on dialysis, and the kidney doctors themselves wrote in the chart that I was to stop taking the blood pressure medicine I was on before this, because it can make the renal failure worse. And, this is actually very well known in all of medicine. I’d expect a second year medical student who is taking pharmacology to know that. I looked at my med list on the discharge orders, and right there at the top it says Lisinopril 1 20 mg daily. I knew enough to not take that medicine, but would almost anyone else? Of course not. I told my surgeon and he apparently went on the warpath to make sure that kind of thing doesn’t happen again. So they’ve greatly improved their discharge process from what I understand.

In addition to being boring, with bad food, and all the annoying stuff I mentioned above, the hospital isn’t a particularly safe place to be, either. Well, that’s not entirely fair I suppose. For things like surgeries and procedures, hospitals have actually done a really good job of improving safety and decreasing error rates. We took a page out of the aviation industry: we have sign-ins, and check-lists, and pre-procedure time outs, and post-procedure sign-outs. These things have really made surgery about as safe as it can possibly be.

No, hospital errors are more insidious than that because there are just so many opportunities for them to happen. Just for one example (and I could give you many), doctors and nurses are constantly transitioning patient care from the person going off shift, to the one coming on shift. This is called the “hand-off” or “check-out.” Ideally, you’re supposed to tell your relief about each patient you’re covering, and what’s going on with them. In actual practice, mostly because medical trainees in the United States are grossly overworked, this is done rather quickly and in very generic terms. Doctors often see people with routine/common diagnoses as being pretty much the “same” admission. For example, if someone comes in with a congestive heart failure 2 secondary to a urinary tract infection, she’s on broad spectrum antibiotics, just waiting on sensitivities 3.” How much does that really tell you about a patient? Enough to cover for the night if the patient doesn’t have any active, uncontrolled problems, perhaps, but very little, overall.

Okay, so maybe that’s a fair way to do it, and maybe it’s not. But the reality is, that’s how it’s done. The real problem was that these hand offs were happening sometimes 2-3x per day. The body that governs resident education, the ACGME, had decided that interns could only work 16 hours in a row, otherwise they’d be “too tired.” They actually just changed this in March of 2017, back to the old system, so now interns can do a full overnight shift again. A 2014 meta-analysis 4 of the 16 hour duty limits failed to show a difference in terms of patient mortality, didn’t improve resident education, and even suggested there might even be a slight increase in morbidity 5. So they went back to the old system where everyone can do 28-hour call shifts, but we can’t work more than 80 hours in a week, averaged over a 4-week period.

In my completely subjective opinion (though it seems the studies also bear this out), it’s better to have a tired resident who knows your case than a well-rested one who doesn’t. Not that the powers that be don’t mean well. I think they really believe they’re making things safer. But this is a classic case of the road to hell being paved with good intentions. When you talk to a patient, when you take their history and examine them yourself, you know that patient. You’re remembering things when you think about them. Things you experienced yourself. You remember the way they said something, or the slight hesitation in answering a question that made you want to clarify something, or ask a follow-up question. In short, you know far more about that person than you’re writing in the note. And you absolutely know more about that person than someone who just inherited that patient with a 90 second blurb about them at handoff. So when a question comes up, you can answer it right away, or can usually remember enough about the patient to figure something out. The person who gets them in handoff sees them as “the CHFer in room 403.”

With too many of these handoffs, it can turn into a huge game of telephone. That’s the one where you whisper something in someone’s ear, and then the message is passed down the line until it eventually gets back to you. Has anyone ever played a game of telephone where the message didn’t get completely screwed up? All it takes is one little misunderstanding to snowball into something much more serious.

People usually start getting out their pitchforks at this point in the conversation. How can hospitals be so dangerous?! What the heck are they doing over there, anyway?! We demand absolute safety! Well, there’s no such thing as that. As with all decisions in life, and with life in general, really, it’s a risk-benefit consideration. Everything carries risk. The real question isn’t whether medical mistakes can happen in a hospital. No, the real question is this: do the benefits of your being admitted (being able to get tests, see any kind of doctor, get procedures done, etc.) outweigh the risks of being admitted?

So it’s more like, “we want you to be in the hospital for as long as you need to be, and not one day longer.” Sometimes, you just have to take the risk of medical error like that, because your general medical condition is such that being admitted will do you more good than harm. And it’s not like we’re just being blasé about medical errors. We’re constantly doing quality improvement projects and tracking outcomes to make sure things are getting better. Doctors and hospitals don’t want to hurt anybody, but the reality is that medical errors are going to happen from time to time.

But you know what else? I think the rate of genuine malpractice-level medical error is actually very low. I think the numbers tossed around in the studies you hear about on the news are sensationalist bull excrement due to their very poor methodology. They like to take a small sample and then multiply it by a huge number so their sample is the same size as the general population, which makes it look like there are tons of errors. But, I’m getting off on a tangent, here. The point is, you only want to stay in house as long as you need to, and as soon as things can be managed in the outpatient setting, it’s time to go home. And for me, it was rapidly approaching time to go home.

Continue reading in the next installment by Christopher Graham here: Chapter 5 | Part 4: A Few Short Days of Freedom

Read the previous installment by Christopher Graham here: Chapter 5 | Part 2: An Existential Journey

Notes:

  1. Lisinopril is an angiotensin-converting-enzyme inhibitor (ACE inhibitor). It’s not a good idea to use them in patients with acute renal failure and low blood pressure (aka, this guy, at the time) because it can worsen their kidney injury.
  2. CHF is when the heart is unable to pump sufficiently to maintain blood flow to meet the body’s metabolic needs. Put more simply: your pump ain’t pumpin’ like it should. 6 exacerbation, pretty much everyone knows what needs to be done – you’ve gotta get the extra fluid off of them one way or the other, and you have to get them on medications to help the heart work better. So, there’s a kind of shorthand that’s used where a patient will be referred to in terms of their diagnosis and what kind of admission it is. “Smith is a routine CHFer who just needs this lab followed up on, he’ll be discharged tomorrow,” for instance, or, “Jones is lady with sepsis 7Sepsis is a blood stream infection, and there are varying degrees of severity of “sepsis.” A UTI is a urinary tract infection. It’s not uncommon, particularly in the elderly, for simple UTIs to progress to blood stream infections.
  3. When someone has a bacterial infection, you’re never sure exactly which bacteria is the culprit or which antibiotics will work to treat it. So you put them on “broad spectrum” coverage, meaning a heavy-duty IV antibiotic that can treat all kinds of infections. Then you culture the bacteria in the lab and test it against a variety of antibiotics to see which one works. You have to get the patient on an antibiotic they can take by mouth (and therefore off of IV antibiotics) before you can send them home, and getting sensitivities done is a big part of the treatment.
  4. A meta-analysis is when researchers take the raw data from multiple studies on a given topic, in this case the duty hours, and put all that data together and then analyze it collectively. Generally, we consider a well-done meta-analysis to be the best kind of evidence because it has higher statistical power than any of the smaller studies from which the data is taken. Of course, you still have to do a good job picking which studies to include in the meta-analysis, because if you put garbage in, you get garbage out.
  5. Ann Surg. 2014 Jun;259(6):1041-53

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