Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

How patient education can save lives

David M. Mitchell, MD, PhD
Conditions
June 4, 2022
Share
Tweet
Share

A patient undergoing chemotherapy for breast cancer was diagnosed on April 20th with profound secondary adrenal insufficiency (hypophysitis: ACTH undetectable, cortisol 0.2) caused by immunotherapy (pembrolizumab). She was started on corticosteroids and sent home from the hospital on April 24th with a prescription for only five days of prednisone. After completing the five days of prednisone, she predictably began to feel profoundly weak and nauseous. She continued losing weight and was unable to eat. Finally, after developing a fever, her family brought her to the emergency department for evaluation on May 15th.

Despite easy access to her recent hospital records, the emergency physician promptly diagnosed her with septic shock due to a urinary tract infection and called the hospitalist for admission. After at least a couple of hours in the ED, the patient had already received a full sepsis fluid bolus, antibiotics, cultures, and was subsequently placed on a norepinephrine drip due to refractory hypotension.

Something wasn’t right, though. Her symptoms had reportedly gone on for weeks before admission, yet she had a normal white blood cell count, and her lactic acid was only slightly above normal range. The hospitalist asked the ED physician by phone if something else might contribute to her hypotension, maybe cardiogenic or hemorrhagic shock. Nope, he was told.

In less than a minute, the answer was apparent. The discharge summary from April 24th clearly listed “adrenal insufficiency secondary to chemotherapy” as a top diagnosis, and the patient was shockingly not taking any corticosteroids. Within moments, the hospitalist called the ED physician back and asked him to immediately give intravenous hydrocortisone.

Within 24 hours, the patient felt remarkably better, and she had an appetite for the first time in weeks. Her urine culture grew E. coli, and she was treated for the infection, but her adrenal crisis likely played a large role in her overall clinical status. If corticosteroids had not been started, the outcome could have been much worse. It is also scary to think that if the patient had not developed a fever, she might have stayed home longer, weakened further, or even died.

There is often a combination of errors in such cases that leads to the adverse outcome. In this case, the discharging hospitalist failed to prescribe long-term corticosteroids, and the patient did not have a prompt follow-up with her oncologist. Perhaps the electronic medical record had a default of five days of prednisone built into the orders that the hospitalist clicked on inadvertently.

I was the hospitalist who admitted her on May 15th. When I evaluated her in the ED, she was surrounded by multiple family members, all very concerned. The patient and her family were clearly intelligent enough to understand the concept of adrenal insufficiency and the importance of long-term corticosteroid therapy. This reinforced what I have always believed: Educating the patient and family about their medical conditions is probably the most important safety measure we can take.

Imagine if the patient (and family) had been carefully taught this at the time of discharge: “You have a serious condition called adrenal insufficiency. This means that your adrenal gland, which makes cortisol, is not working. Your body absolutely needs cortisol to survive. So, you will very likely need to take some type of corticosteroid for the rest of your life, every day. Never let your prescription run out, and never let a doctor stop your corticosteroids without a good reason. Now, can you teach me what I just told you?”

This is the conversation I had with her and her family in the emergency department, and every subsequent day she was in the hospital.

Even if we provide excellent care in every way, if the patient doesn’t understand their disease, the risk of adverse events remains high. Unfortunately, patient education is not a metric that hospitals or hospitalists are incentivized to achieve. In this case, the quality officers were certainly watching closely to see that the sepsis fluid bolus and antibiotics were given, cultures obtained, and that serial lactic acid levels were monitored at appropriate times, etc., but sadly, no quality officer has ever come to me to check if a patient has been educated about their condition and medications. Despite all of our so-called focus on quality, the quality officer would never have noticed if the diagnosis of adrenal crisis was missed entirely. Unfortunately, that’s how we measure quality these days. We “strain at a gnat and swallow a camel.”

This month, I was pleasantly surprised when I reviewed a medical record of one of my patients who had recently been at the University of Virginia Medical Center in Charlottesville, VA. Through remote access, I found both a standard discharge summary (for doctors) and a second discharge summary written for the patient (in simple terms). Impressive. It’s extra work for the doctor, but it’s a sign that someone is thinking “outside the box” about patient safety. How would your hospitalist team react to such a requirement–to write two discharge summaries? What would their response say about their priorities?

Too often, when admitting a competent patient with a recent hospitalization, I find that they have little to no idea what happened during the previous hospitalization. Some doctors would blame the patients for not having the capacity to understand medical topics. An old doctor I worked with as a medical student used to say, chuckling, in response to a patient’s question about their medical diagnosis: “Oh, you’d have to go through four years of medical school to understand that!” Honestly, I think he just wanted to move on to the next patient. Certainly, some patients cannot understand the complexities of their medical conditions, but we should at least take time to explain, in simple terms, the most critical aspects of their disease; or reach out to an engaged family member.

I fear that with pressures like “discharge before noon,” hospitalists are forced to rush patients out without taking time to do a very important thing: educating the patient using the teach-back method. As professionals and as a specialty, hospitalists need to step back, awaken our common sense, and take time to teach our patients. It could save their life.

ADVERTISEMENT

David M. Mitchell is a hospitalist.

Image credit: Shutterstock.com

Prev

What you need to know about monkeypox

June 4, 2022 Kevin 0
…
Next

How to solve burnout with communication [PODCAST]

June 4, 2022 Kevin 0
…

Tagged as: Endocrinology, Hospital-Based Medicine

Post navigation

< Previous Post
What you need to know about monkeypox
Next Post >
How to solve burnout with communication [PODCAST]

ADVERTISEMENT

More by David M. Mitchell, MD, PhD

  • How America’s health care system depends on international doctors

    David M. Mitchell, MD, PhD
  • Creating a subspecialty track for experienced hospitalists

    David M. Mitchell, MD, PhD
  • Health care administrators: a call for equal transparency and accountability

    David M. Mitchell, MD, PhD

Related Posts

  • Medical education must be patient-centered

    Christian Rubio
  • A letter to a cancer patient in palliative care

    Alison Vasa
  • My first patient to be diagnosed with cancer

    Ton La, Jr., MD, JD
  • Osler and the doctor-patient relationship

    Leonard Wang
  • Treating the patient’s body is not synonymous with treating the patient

    Steven Zhang, MD
  • A silent moment with a dying patient

    Ramses Perez

More in Conditions

  • How President Biden’s cognitive health shapes political and legal trust

    Muhamad Aly Rifai, MD
  • The emotional first responders of aesthetic medicine

    Sarah White, APRN
  • Why testosterone matters more than you think in women’s health

    Andrea Caamano, MD
  • How veteran health care is being transformed by tech and teamwork

    Deborah Lafer Scher
  • What Elon Musk and Diddy reveal about the price of power

    Osmund Agbo, MD
  • Understanding depression beyond biology: the power of therapy and meaning

    Maire Daugharty, MD
  • Most Popular

  • Past Week

    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
  • Past 6 Months

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
  • Recent Posts

    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Decoding your medical bill: What those charges really mean

      Cheryl Spang | Finance
    • The emotional first responders of aesthetic medicine

      Sarah White, APRN | Conditions
    • Why testosterone matters more than you think in women’s health

      Andrea Caamano, MD | Conditions
    • A mind to guide the machine: Why physicians must help shape artificial intelligence in medicine

      Shanice Spence-Miller, MD | Tech
    • How subjective likability practices undermine Canada’s health workforce recruitment and retention

      Olumuyiwa Bamgbade, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 2 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
  • Past 6 Months

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
    • Why Medicaid cuts should alarm every doctor

      Ilan Shapiro, MD | Policy
  • Recent Posts

    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Decoding your medical bill: What those charges really mean

      Cheryl Spang | Finance
    • The emotional first responders of aesthetic medicine

      Sarah White, APRN | Conditions
    • Why testosterone matters more than you think in women’s health

      Andrea Caamano, MD | Conditions
    • A mind to guide the machine: Why physicians must help shape artificial intelligence in medicine

      Shanice Spence-Miller, MD | Tech
    • How subjective likability practices undermine Canada’s health workforce recruitment and retention

      Olumuyiwa Bamgbade, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

How patient education can save lives
2 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...