My 74-year old obese, poorly controlled diabetic patient with high blood pressure, high cholesterol, coronary artery disease, asthma, obstructive sleep apnea has been difficult to motivate to improve his lifestyle and his health. He is bright, sweet and caring but just not very disciplined.
At each office visit, we review his medications, review his dietary habits and go through the check list of check-ups for diabetic complications including regular ophthalmology exams and podiatric exams to prevent diabetic retinopathy and foot skin breakdown and infection. His spouse is always present, and we discuss seeing his endocrinologist regularly, and a dietitian who specializes in diabetes care all the time. To no avail, I have suggested seeing a psychologist.
Three months ago, two weeks after his last office visit, his wife self-referred him to our local community hospital Emergency Department for a small ulcer at the base of his toe. He was seen, treated and referred to that hospital’s therapy and wound care center. I was listed as his primary care doctor. He was seen by the ED, but I was not called or informed of the visit. He has continued to see wound care regularly but, to date, I have received no notification of the problem, the visits, the ongoing therapy, the prognosis and/or the results.
I became aware of the situation when at the end of a long day an emergency department physician contacted me.
“Dr. Reznick, we have your patient here. He was seen in the wound care center earlier today for ongoing treatment of an enlarging diabetic foot ulcer. The podiatrist debrided the wound surgically then put a bandage on it and a fiberglass cast. One hour later the patient called the wound care center complaining of shaking chills and rigors. He was told that no one was available at wound care to see him and was referred to the emergency department. He is currently running a low-grade fever of 100.8 with a mild elevation of his white blood cell count and says his leg feels the way it did when he had a cellulitis infection. His blood sugar is 256. He is well hydrated. I plan to culture him up, start him on oral antibiotics and refer him back to you for follow up tomorrow if that is OK.”
I suggested he open the cast, take down the bandage dressing and observe the wound and culture it first. He told me he would call the podiatrist from wound care because he didn’t want to “mess with” the cast.
Twenty minutes later he called back.
“The patient is refusing to go home. He wishes to be admitted to the private suites section of the hospital. When I told this to the podiatrist, he said he would come in tomorrow to look at the leg.”
I asked the ED physician to cut off the cast and remove the bandage, and I was on my way in to see the patient. I asked him if he felt the patient needed to stay.
He replied, “The patient wants to be admitted, and I do not want him to give me a poor patient satisfaction report, so yes he needs to be admitted. The patient satisfaction report may not be important to you private physicians, but it could cost me pay and my job.”
There is nothing like assuming the care of a problem that occurred within a large health care system that is clearly interested in generating revenue for services rendered but not necessarily providing continuity of care and communication with its staff so that the patient is treated well. It is irritating and frustrating to not be included in the health care process but called in out of the bullpen after hours for something that should not have occurred in the first place.
When I arrived in the ED and went down to the patient’s room, I was greeted by the patient’s wife. The cast was still on. I paged the podiatrist and reached him ultimately by cell phone. I politely made it clear that I expected him to come in now, remove the cast and take the bandage off so I and the infectious disease expert I was consulting could observe the wound, culture it and make a gram stained slide so we could choose the correct antibiotics for this situation.
“Why?” he asked suggesting that the culture would show a conglomerate of multiple organisms.
“Because infectious disease will want a culture and a gram stain unless they suddenly have started to operate differently and because it is good medicine.”
I took a thorough history using my office notes as well and was disappointed and surprised to learn that although at each visit he confirmed that he was seeing his endocrinologist and spoke to him, he actually had not been to his office in over a year.
The admission process takes well over an hour for me. Writing an admission note and entering orders and medications on the hospital’s computer order entry system is slow and cumbersome.
At the completion of the process, I walked into the room and reviewed my findings and suggestions and asked if the patient had any questions. His wife had one question.
“Three months ago at wound care, I showed the doctors an article about the benefits of using a product called Duoderm on diabetic foot ulcers. I asked if it would be helpful for my husband. They said it would be beneficial, but it was too expensive, and they were not allowed to use it.”
She asked them to write out a prescription for it, and she would pay for it privately if they would use it. They refused saying they were not allowed to use nonformulary items. I told her I was sorry and suggested that in the future if she runs into a roadblock she should call me.
I admitted the patient to the hospital, cultured his blood and urine and asked for help from an experienced endocrinologist and infectious disease expert with his antibiotics and diabetic care. I returned several hours later to find the cast off, the wound bandaged but no wound culture obtained by the podiatrist from our hospital wound care center. I asked the nurse for sterile gloves, supplies to create a small sterile field and culture tubes when the infectious disease physician walked in and relieved me of the task. We used the gram stain of the specimen to help direct initial antibiotic choices while awaiting the culture results. A subsequent MRI of his foot revealed that the infection had spread to the base of the bone in his big toe. This will now require 6 to 8 weeks of intravenous antibiotic therapy to try and save the foot.
I had been a patient at the same not-for-profit local hospital several weeks before for an inpatient urologic procedure. When I woke up from anesthesia with an indwelling urinary catheter in place, the surgeon was there to report on the procedure.
“It went well,” he said, “but the damn cheap products the hospital is supplying us with make it highly likely that the catheter will kink up on you and put you into urinary retention. I should have brought some supplies from my office because this doesn’t occur with the products I buy and the hospital used to buy.”
The catheter did kink numerous times requiring intervention and eventually a late night visit to his office for him to change catheters and leg bag so that the urinary drainage was not obstructed. When it is kinked and urinary flow is obstructed, and your bladder fills, it is very uncomfortable.
As a board certified internist with experience in geriatrics and hospital staff privileges for 38 years, it is disconcerting and frustrating to see the direction of hospital medicine. It is unclear to me if using Duoderm on my patient’s foot ulcer would have prevented his failure to heal and bone infection. It is clear that his wound caregivers thought highly of the product but were clearly intimidated to write a script for it even if the patient paid for it themselves.
It is sad that the ED physician wouldn’t justify his decision to admit the patient to me by simply saying his clinical situation warrants it. To be afraid of patient satisfaction rating as the reason for suggesting he stay is disheartening. To purchase less expensive urinary catheters which the surgeons clearly know is problematic and add pain, discomfort and additional costs for physician and nursing time is inexcusable.
If this is the direction hospital care is traveling, I feel sorry for our patient population. I will address these issues with hospital administration and our medical staff officers directly for whatever it is worth.
Steven Reznick is an internal medicine physician and can be reached at Boca Raton Concierge Doctor.
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