Friday, November 25, 2011

A memorable patient!

     I announced about a year ago that I would use the Caduceus to announce postings that are medically related, or that relate to my life as a physician. (Posting for Nov 10, 2010: An Obituary Tells a Story). After that posting, I went on to research the Caduceus and discovered I was way off base. The symbol that I thought represented medicine was not the Caduceus or Staff of Hermes but rather the above symbol, the Rod of Asclepius. (Posting July 7, 2011: Medical Confusions: Staff of Hermes vs Rod of Asclepius). So from here forth, I will use the above correct symbol of medicine when my posting relates to that topic.
     Read on for a story of one of my more memorable patients.

     In this posting, I would like to tell about one of my most memorable patients. Kenneth, Mr. Q,  presented to me after just a few years of my practice.  As I entered the exam room, a medical relationship began that was to continue for about 20 years. He was balding and what hair he had left was graying. He was mildly overweight, dressed in bluejeans and a T shirt with some fading black and white logo on it that had no meaning for me. His T-shirt included a left breast pocket that was very necessary for Mr. Q because it was stuffed with about 15 pens and at least two pairs of sunglasses in cases. He also wore a third pair of sunglasses on his face, even in the exam room.  As I introduced myself and came into the room to sit at the desk, Mr. Q referred to one of the three watches on his left wrist, pulled out a small white spiral notebook and jotted down the time with a pen from his pocket. I debated whether to ask him what that was all about, but at that juncture did not ask. I began with the usual questions: What brings you in today? What is troubling you? What can I do for you today?" Mr. Q. was very talkative and immediately launched into a long description of multiple aches and pains and self-diagnoses " too much acidity in my body" mixed with diagnoses that previous doctors had given him. Mixed in with this long description was a diatribe against every doctor that he had previously seen in his life. There was a subdued anger portrayed when these comments were inserted. And he would look at me, now without his sunglasses, with a tilted head from beneath half lowered eyelids that gave him a somewhat frightening beady eyed appearance.
     Now I prided myself on being able to handle most exam room situations and determined to try to get down to one or two of his complaints during this visit and see if they represented concern, to determine if they needed further evaluation, and then to try to come to some suggestions for remedy. It didn't take long for me to discover that these simple goals would be impossible to achieve for Mr. Q. in a single visit. Clearly some of the complaints and railings against the medical profession were not signs of a healthy psyche, but yet there was something about Mr. Q. that made me want to try to help him. During future visits, I began to think that most physicians would probably be so off put by this man  that they would seek his disappearance as their patient. Perhaps his complaints against previous doctors who had ignored him or who had belittled his complaints were true. They were probably attempts of former doctors to let him wander (hopefully) on to another doctor.
     But I didn't fire him or ignore him. I don't know why. It would have been much simpler to just tell him to seek care elsewhere -- that I didn't think I was going to be able to help him. But maybe I regarded his strange persona as a challenge. And I think in the beginning with those beady black eyes looking at me, I was a little afraid of him. I was afraid if I fired him, I would be listed among all his doctor complaints to someone else down the road. And I think as some points I feared that he would retaliate against such an action by doing me some harm. As time went on and visits piled up, I came to know that he was essentially harmless. And on top of that I think he came to respect me as his physician and listened to what I said.
     At some point, I asked him what he was writing in his book, when he always pulled it out of his pocket as I walked into the exam room. He finally showed me. He was keeping track of the time he was kept waiting in the reception area, in the exam room before I entered, and then finally of the actual time that I spent with him in the exam room. He had pages of this data. He also wrote down some things that I advised him., names of specialists I might have referred him to and other items that I thought were very appropriate to note down.

     When Mr. Ken Q. first came to me as a patient, I was hand writing my documentation notes in the paper chart while I was with the patient -- at least I noted the history down right there with the patient. Sometimes I documented the exam and tests ordered at that same time; sometimes I caught up with the latter data later that day, or if I really got behind in office visits that day, I would have to catch up that evening or the next day, writing in several of the charts. So in the beginning while Mr. Q jotted down his times and notes, I wrote notes about him: "Same complaints today. Seems very concerned about 'acidity in his body.' Says his dentist finds the enamel being eaten from is teeth because of his acidity. Chest pains the same -- nothing that sounds exercise induced." I had witnessed other doctor's chart notes and at this time, some were just squiggled words, abbreviations, and  often indecipherable gibberish. But as time went on the requirements for documentation became more stringent and more voluminous. The documentation was not only used to remind the doctor and other caretakers what had been discussed and what had been examined or ordered during the visit. More extensive documentation began to become necessary to prove to Medicare and to the insurance companies that you had done this for the patient and the level of service charge had to be justified by the office note. If several complaints were dealt with during the visit and a more complex list of complaints were analyzed and treated, more complex orders of tests and/or medications also justified a higher charge. All of this had to be proven in the records. It became difficult to do this by just hand written symbols and words, but I stuck out handwritten notes as long as I could.

     With Mr Q, the most difficult thing to deal with was his excess of complaints. They were usually about the same: back ache, neck aches, headaches, upset stomach, chest pains, and diarrhea off and on. Over time I did a lot of tests, repeated GI studies and various spinal Xrays, got some consults from orthopedics, and gastroenterology. I had him see a dermatologist a couple of times about some questionable skin lesions. I always heard back from those specialists: "What kind of patient are you sending me? He is totally crazy!." Those specialists treated him to the best of their ability but always let me know they really didn't want to continue to see him regularly.
     At some time during my care of him, I felt we had exhausted the need for further testing and evaluation. I had reviewed old records about previous workups and had filled in any blanks in those workups. I felt I had essentially ruled out medical causes of his complaints. I had suggested some psychiatric help but Ken's insurance would not cover that and he was unemployed. He would not have been able to pay for such care. So I decided to do some simple counseling of my own. I had read about treating hypochondriacs and obsessive compulsive patients by taking advantage of their long lists of complaints and their need to keep track of everything, by having them apply these lists and enumerations to their lists of complaints. I didn't keep this a secret from him. I told him that I had an exercise for him and that I had read that sometimes exaggerating the complaints and his keeping track himself of these complaints helped his mind to overcome them. He tried my technique, and came in with exhaustive lists and timings of his aches and pains. He thought this might be doing some good and we continued it for a while but he slowly slipped back in his sufferings. It became a situation where I didn't think I was really doing anything for Ken. He would come in and list all his complaints. I would listen, and make some documentations in the chart. I would review his medications and how recent we were with his various tests; was it time to repeat yearly exams etc. Sometimes I would examine some part of his anatomy that was hurting or causing symptoms, but mostly I would listen and he would recite. I seldom did anything else for him. I wondered why he kept coming back for office appointments, but for years he did. He never demanded more from me. I don't know -- maybe just venting his complaints did him some good.

     Finally I could no longer hand write everything that needed to be written about each patient visit. I had to start dictating. My obstetrician had a habit of dictating his note to his nurse while he was in the exam room with me as his patient. So I decided to try that technique, but instead dictating my notes into a handheld small recorder, like so many of my colleagues did. I found that if I dictated at least some of the information with the patient, the patient liked to hear what I thought and what I put in the record. They would sometimes correct something that they thought I hadn't perceived exactly correctly. Ken always listened with great interest. I am sure he had always wondered what I wrote about him. I had to be a little careful what I dictated in front of him -- nothing that he might regard as derogatory or insulting. Well, that should be true of any patient anyway. But we doctors do have various statements that we use to communicate to another doctor that this patient has some psychiatric issues, or that he is a difficult patient, or a little hypochondriacal. "I believe his complaint of heartburn and chest pain are really supratentorial in cause." Supratentorial refers to an area above the ligamentous support of the brain -- ie "in his head."  I couldn't use those phrases in front of Ken. He wanted to know about every symptom and every medical term that I used in my dictation. he was very curious and wanted to learn. He was a self educated man. But he was also driven to know my internal reasoning in my conclusions about his care. I soon ceased doing the dictations in Ken's presence because it extended an already very long office visit. So for Ken I sometimes made a few hand notes to remind me of what we discussed and then dictated the note after I left the exam room.

        One positive thing I will say about Ken was that he did not make unnecessary calls for medical help in off hours. He was not the typical hypochondriac that makes himself a nuisance. I basically only recall two calls from him after hours and  both were about serious issues. One was when he was passing a kidney stone. I sent him to the Emergency Room where he received treatment for his pain and was admitted overnight. He passed the kidney stone and was all right after. The other need for emergency treatment scared me and made me realize that even in a hypochondriacal patient, you can never truly assume anything about their medical condition. Ken went to the ER one time with chest pain. Now chest pain had been on his list of complaints for years. I spoke with the Emergency Room physician after he had a chance to evaluate him. We commiserated over the fact that this pain likely did not have a physical cause. But Thank God, we both decided that the safest thing to do was to admit him to the hospital for observation, and to get the usual testing done to rule out coronary artery disease as cause for his appearance in the Emergency Room with chest pain. In spite of years of complaints of chest pains, indeed he had never called me after hours or appeared in the Emergency Room with this complaint. Low and behold in a couple hours the blood tests that show a heart attack came back abnormal and his EKG also showed that he had had some minor heart damage. He had coronary artery disease! He had real and serious disease. Fortunately he was not seriously affected by the small heart attack, but now it was going to be even more difficult to take care of him, because we would never be able to assure him or ourselves that his chronic chest pains were not recurrences of his arterial disease. Well, we just proceeded and he added a cardiologist to his list of specialists. Fortunately, that doctor took his care in stride and had no complaints to me about him. He understood the psychological issues but he always paid attention to Ken, and treated him with full respect.

     In the late 1990s the requirements for documentation of every interaction between doctor and patient became almost unmeetable. "Doctor, if it isn't written down, you didn't do it." The insurance companies told us this; the lawyers emphasized it even more when we had seminars about litigation prevention. At this same time we began a long switch over to computerized medical records. I was one of the few doctors who typed the documentation right on the computer while in the exam room with the patient. When I was in high school I decided that I wanted to learn how to type; I thought I could use it to type up my papers and reports while in college. At that time typing was taught as part of a program to teach the high school girls how to become secretaries. Shorthand and typing were taught as those skills. The class grade depended on speed and accuracy. I knew then that I was going to college and I really was not interested in being graded on those two marks of proficiency. I just wanted to know how to type reasonably well and with some degree of accuracy. I was afraid that if I didn't meet the proficiency benchmarks, I would receive a B. I was striving for straight A's. I didn't want a grade in that course to ruin my grade point average, so I talked our principal into letting me audit the class during my normal study hour time. I used the typing skills so gained in college and even made a little money typing other student's term papers. But after college I had no use for the skill. Apparently though it's like they say about riding a bike, because when I began typing on the computer, my speed and accuracy returned quite nicely. I could really pound those keys. Usually people were not seeing the computer screen while I entered the data, and most patients didn't ask about what I was writing. They just commented on what a fast typist I was. But Ken always asked me to turn the screen so he could see what I was writing. Fortunately for me though, his chronic stiff neck precluded him from following my fast typing and he usually couldn't ask too many questions about what I wrote.

     As the years went by, I slowly learned more about Ken. He lived with his mother, in the house she owned. He had once had a girlfriend and had intended to get married but the relationship didn't last. On some occasions I thought that he had created the girl friend in his mind . I never met her in all of the years of my care of Ken. Slowly over the years two things happened. Ken's mother died and he slowly became more reclusive. Then he told me that his girlfriend had moved away. He began not showing up for his appointments with me. And when he did come in he was more unkempt. He now had long white hair down to his shoulders, with the top of his head bald. He would disappear from my practice for months at a time. Then he would reappear and see me regularly for a few months.
     On occasion he would show up in the Emergency Room and was found to be in a weakened condition and dehydrated. He had called an ambulance to come to his home and the attendants reported that he was living in squalor and was found on the floor or in a chair unable to stand or walk. We would admit him to the hospital, get him rehydrated, and apply some physical therapy and get him tuned up and back home. On one or two occasions I even got him admitted for a time to a nursing home. He really did very well in the nursing homes. When I went there to visit him, he would be sitting in a chair by the door, greeting everyone who came in in a very warm and hospitable way. He really could be quite charming. He had gained some weight, was nutritionally better and was walking well by himself. But even though the home had him very nicely socially occupied, he wanted to go back home.After being back by himself for several months, he would again fall back into his reclusive agoraphobic behavior. He became so agoraphobic that he could not even bring himself to take his garbage cans out to the curb for garbage pickup.  On two occasions I learned Ken had a brother who lived in Hawaii. On one occasion a neighbor called his brother who came to visit him and to try to clean things up in his home. On another occasion I called and spoke with Ken's brother. But on both occasions the brother had to return to Hawaii and after he left, Mr. Q went back to his old ways.

     Meanwhile on the doctor's side of the desk, I felt that day to day practice was getting more and more difficult. We were now subject to chart review to see if we were documenting all the correct things. There were actually bullet points that had to be included in each patient visit note. Some reviewer somewhere (possibly just someone with a high school education, or maybe a nurse if we were lucky)-- that reviewer was counting these bullet points to see if there were enough to justify the charge code and the diagnosis code that we entered in the record. We received a score, a grade if you will on how well we had all those bullet points. In some cases, only certain wording was recognized by the reviewers. If you didn't have the correct wording that description would not be counted and it would not be counted as a bullet point. Without a few of these bullet points, maybe you charged too much and could be accused of Medicare fraud. Then we began receiving performance grades. What percentage of our patients were up to date with their mammograms? Were our diabetics' blood tests showing that their sugars were adequately controlled? Had we stripped our diabetic patients' feet and examined their feet and documented this foot exam in the chart with each visit? Had we asked questions about the temperature of the hot water heater in our elderly patents' homes and documented this preventative answer? It got more and more ridiculous. One could spend the entire 10 minutes of the appointment just documenting all of these things without even considering the actual doctoring that needed to be done -- taking the history, doing an exam, determining tests to be done, reporting the results, coming to a conclusion, making a treatment suggestion and explaining all this to the patient. At the end of the day, I would go home exhausted. I felt like I was in a brain drained condition after doing all that I had to do each day -- the doctoring and the data entry -- two full time jobs during the same period of time. I began to think about retirement.

     I am sure Mr. Ken Q was depressed but he also seemed not interested in living. Things continued like this with me seeing him during hospital re admissions.  He basically fell through the cracks of medical care because he always fell back into his reclusive way of life. And then finally I received a call from the Emergency Room. Ken had been found by a neighbor unresponsive in his chair at his home with evidence that he had probably not moved from that chair for days. He was dead at his arrival to the Emergency Room.
      I recall a feeling of failure when I received this news. What could I have done differently for Mr. Q? How could the medical system  have dealt better for him. He had had psychiatric consultation but he never would follow up with the psychiatrists after his discharge from the hospital. And he refused to settle into a long term nursing home stay even though to all intensive purposes he perked up while in the nursing home and became very social. I am sure even though much of the pain we could not find an organic cause for, this pain was very real to Ken. He had suffered from it most of his adult life. He had various medications to try to lessen it but nothing made it go away. We did not have him on narcotics or anything like that and he never asked for such medications. He lost his mother and he lost his girl friend. His brother was not living nearby. He had absolutely no one else. I think he just lost the will to continue living. He was 69 years old at that time. It is proven in all sorts of scientific studies, that one of the most important predictors of survival is the presence of  the support of family or friends. Without such support and such people, the individual literally becomes physically ill. That is indeed what I think happened to Mr. Q -- he simply sat in his chair in his home until he died.

     I loved taking care of patients of all kinds, even the Mr. Ken Qs of the world. But the peripheral parts of practicing medicine in the 21st century -- the documentation, the report cards, the pay for performance measures and benchmarks, the battles with insurance companies and Medicare to get paid for the time that you have put in became too much for me.  I decided I was not going to die at my medical documentation computer. I retired from the practice of medicine. Ah, but now I am sitting at my laptop again typing. Writing on my blog. But this is much more fun.

No comments:

Post a Comment