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The Broken US Patient Visit

Megan has a swollen painful right great toe andĀ thinks it’s probably just gout from what she read online but she also has diabetes so she is worried it’s infected. She calls her health insurance’s advice line to see what to do. They ask her a long list of questions and then transfer her to an advice nurse. The nurse hears the words diabetes and toe redness and directs her to the urgent care per the protocol on the computer. Patient arrives at the urgent care, waiting among a dozen or so other patients, some coughing and some sprawled out on the waiting benches. There are patients entering and leaving the exam area but Meghan doesn’t know when her turn is and she starts doubting whether she needs to even be there. But she has already checked in, paid her $50 and wondering if they are gonna charge her anything else. After all, the insurance companies have put in a lot of effort to make sure the patient remains very confused as to what is charged for what.

After getting coughed on and witnessing the snotty toddler running all over the place and rubbing his face and hands on the furniture she is called back. A person who appears to be a nurse asks her a bunch of repeat questions while also directing her where to go. The person in the scrubs seems rushed so Meghan just follows the instructions. She doesn’t know where to put her stuff in the exam room so she puts it on the chair not knowing the 350 lbs patient seen in this room before her sat on that same chair without the best of personal hygiene standards. She gets a probe stuck in her mouth, a cuff on her arm and she gets up on a scale all the while thinking ‘I wonder what my temp was’. The nurse then says ‘the doctor will be in shortly’. She waits, and waits, she can hear the conversations in the next room. She is rehearsing what to say to the doctor because the wrong thing could maybe lead to a misdiagnosis? Or if she doesn’t say the right stuff she’ll just get sent home and what if the doctor misses a serious infection! She is wondering how clean this exam room is. Why didn’t the nurse wash her hands? Why did she need her blood pressure and weight taken?

The doctor finally arrives and she definitely appears distracted and rushed but she is attentive and addresses Meghan by her first name and knows a little about her medical history and the diabetes already but asks “What are you here for today?”. So Meghan tells the story for the 4th time and the doctor asks pretty much all the questions she expected. Touches her painful toe, goes back to the computer typing some things, asks her about gout and fevers. She thinks it’s just gout but she wants a xray and a serum CBC test. Meghan is too embarrassed to ask if it’s gonna cost her extra and doesn’t want to keep the doctor longer but is also annoyed and worried she may have more costs. So… the doc steps out, nurse comes in, Meghan walks to the lab and pays $20, waits over at xray and pays $25. She then walks back to the doctor’s waiting area, sees a few more people go in and out. Gets called, goes back to the exam room and waits for the doctor. Doc says “Yeap, it’s gout, you need 2 meds and you gotta change your diet, I’ll print that out for you, the meds are the pharmacy”. Meghan asks a few questions about gout and diabetes and the meds but the doctor now is curt and directs her to the pharmacy and the paper that she will soon get. Doctor leaves, nurse comes back in and she gets some papers and is directed to the pharmacy. Megan waits at the pharmacy and pays $30 for her meds and while waiting she is reading over the gout information which she had already looked at online but despite all the expenses she is really happy it’s not a toe infection. Though she is still wondering in the back of her mind ‘what if the doctor missed an infection, I don’t want to lose my toe!’. How did the xray show that it’s gout? What is she supposed to eat now because she already gave up bread and rice and now she has to give up beans and seafood? Is she damaging it by walking on it? Is gout for life? Does she have to come back next time she gets this?

The doc started her shift at 1pm and rushed to get in because she had some errands to run and tried to get a workout in. She knew she was a little distracted that day because she had to catch up on some charts from the night before. She was getting calls from the pharmacy a few times while seeing patients mostly about refill of chronic pain medications. While in the room with Meghan she felt a bit rushed because she was managing a patient with fever and abdominal pains in another room . At the same time she really liked Meghan, she actually thought to herself ‘Gosh, what a sweet lady, let me put her mind at ease about this toe thing’. She looked at the toe and knew very well it was gout… almost 100%… ok nothing in medicine is 100%… I mean it’s gout, she could just tell her to take it easy and even with some Advil it would go away quickly and with some dietary changes it probably wouldn’t come back. But Meghan was a diabetic, what if it was an infection and she misses it? If she orders the xray then the patient will go to the lab and that’ll give the doc a chance to go see the next patient, she’ll actually catch up. Yea but the poor patient has to sit and do the lab and xray and probably pay for it and then there is the radiation… wait a minute, but if it’s not gout and she loses her toe she’ll get sued and… forget it, get the xray and CBC, skip the uric acid and have her follow-up with the primary care doctor. Dang it, what if the xray and CBC misses it too and she decides not to follow-up for the toe and it really IS an infection? The doc decides to have the nurse book an appointment for Meghan in one week with her primary care doctor. Ok good, now she feels the patient is tucked in!

Not only was the doc working up the abdominal pain patient but she was finishing up 2 charts before even starting on Meghan’s chart. She was answering those phone calls and she knows there is a chest pain with shortness of breath on her schedule that she has to see still but they aren’t even checked in yet. She is trying to be as thorough as possible when documenting everything, not for the purpose of follow-up because come on… it’s gout.. it had to be… the next doc that might see her probably won’t even look at her note. But in case it’s not gout or in case she also gets an infection while the toe is inflamed she has to chart enough that it will hold up in court. And if the patient files a complaint that she rushed in and out then her chart also better be really thorough and so she’ll throw in a couple of sentences saying that ‘the patient’s concerns were addressed and the meds and gout diet was reviewed’. And then she realizes she didn’t even check the patient’s blood sugar or ask what it was. She quickly looks at the last A1C and sees that it was 7.1, not bad. The doc starts typing away at the computer like a robot, has 2 other patient charts open and as she is typing she thinks… how messed up that Meghan had to get blood test, xray, a doctor visit and medications just for gout. But wait, no, that’s how it should be… what if it was an infection and she would have lost her toe, thank goodness she came in. Patients are so lucky to have a doctor here, without the doc these patients would all have really bad outcomes.

How is it that we need a doctor to diagnose gout when any sweet old grammy can tell you it’s gout even over the phone. Why is it we need a xray and uric acid, a CBC and some medications to treat centuries old podagra for such a simple US patient visit?

  • Why didn’t Meghan just go online, consult some friends, show the toe to an elder and then decide what to do next?
  • Why was she so afraid of losing her toe?
  • Why didn’t she contest the imaging and labs and the meds?
  • Why didn’t the doc just go with her instinct?
  • Why was the doctor so rushed?
  • Why is it that the legal system puts millions of dollars of value on a human life and its potential suffering?
  • Why does it punish a doctor’s mistakes yet does not prevent the doctor from being rushed and distracted in the clinic?

The broken legal system won’t pat the doc on her back and forgive her if Meghan ended up having a very atypical toe cellulitis that would lead to an amputation or much worse, sepsis or death.

If the laws are there to protect this typical US patient visit, why is it that the doc practiced defensive medicine? Why is it that Meghan got a bunch of unnecessary tests and treatments? Why is it that the laws expect docs to be infallible? And why is it that a train operator is not allowed any distractions when operating the cockpit while the doctor is expected to juggle patients, nurses, phone calls, and charting?

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