“So how is your pain doing after the morphine shot?” I asked the 87 year old little old lady who had fallen at home.
“I don’t have pain any more,” she replied.
“That’s great! Well I have some good news. The x-rays show a lot of arthritis, but no fractures.”
I thought that the patient and the growing numbers of family members in the room would have been happy with that statement.
I was wrong.
Grandma had fallen when trying to get out of her chair. She appeared frail and it was apparent that ambulation was always going to present a risk of another fall. But she had a walker and she refused nursing home placement, so there wasn’t much else to do to help her.
When I explained my plans to discharge her, I started getting a bunch of questions.
The patient’s husband wanted to know why the patient’s hand shook when she was using a fork at the dinner table.
“Yeah, and why do her teeth chatter when she talks?” asked a granddaughter.
Another granddaughter wanted to know why Grandma wouldn’t use her walker.
Then the patient remembered that her fifth toe and the side of her foot had been bothering her for the past few months.
“Yeah. What are you going to do about that?” demanded a strange male in the room.
“Did all of this happen after her fall?”
“Heck no, she’s been having the teeth chattering problem for months.” Other family members related prolonged and intermittent course of the patient’s other symptoms.
“Have you spoken to your family physician about these problems?”
“No. He doesn’t listen to me,” the patient responded.
Looking around the room, by that time, two of the four family members had their arms folded and were scowling at me. A third was squeezing the patient’s hand – literally to the point that the patient’s fingertips were red. The fourth was pecking away on his CrackBerry.
With multiple family members who appeared dissatisfied, I was faced with a choice: Do I go ahead with my plans at discharging the patient and risk complaints and a bad Press Ganey score or do I perform the Big Medical Workup “BMW” on a patient who could just as easily have had an outpatient evaluation of her chronic symptoms?
“Hold on a minute. I’ll go get the chart so that I can make sure I get all of these other problems written down.”
I spent a lot of time writing down all the other issues, doing a re-examination that showed nothing unexpected for a patient her age, ordering a bunch of low-yield screening lab tests, and even getting an x-ray of that painful toe. Not surprisingly, everything was normal.
“Well, you have arthritis in your foot and all your blood tests were normal. I don’t have a good answer for why your teeth chatter or why your hand shakes. Given your history of falls, you really need to use your walker any time you’re moving about. It’s possible that these symptoms might be the beginning of Parkinson’s Disease but you’ll …”
“WHAAAAT?!?!” blurted out the daughter who had been squeezing the patient’s hand. “How can you say that?!?”
“You didn’t let me finish. I was going to tell you all that she’ll have to follow up either with her primary care physician or with a neurologist to have more testing done.”
Her son momentarily looked up from his CrackBerry screen to ask “If you knew she needed more testing, then why didn’t you just do it here?”
“There are a lot of tests we can’t do in the emergency department. Besides, those types of tests are better done as an outpatient, anyway.”
The hand squeezer mumbled “Great. What a wasted trip.”
So the patient and her family were discharged … most of them unhappily … with hospital charges to Medicare that would easily total several thousand dollars. As the nurse handed the discharge papers to the patient, the hand squeezer told the nurse “that doctor is lucky I didn’t punch him right in the face.”
When the nurse told me that, I sat and tried to retrospectively analyze what I could have done different to make the family happy. I couldn’t think of anything.
The emphasis on patient satisfaction at the expense of proper medical care is a major reason why health care costs in this country will only continue to increase and why medical practitioners are becoming more and more disgusted with the system …
… that is … until the “game changer” is implemented ….