She didn’t have the right doctor
It was December 21st, a Thursday. I was in clinic seeing same day acute care patients, which was kind of a low key urgent care function in a Primary Care clinic. I essentially saw people who called in to see their Primary Care Provider (PCP) but the PCP couldn’t (or wouldn’t) see them. It was about 3:00 PM. I picked up the next patient’s paper chart from the bin outside the exam room and entered the exam room.
There were three people in the room: a really elderly woman (she ended up being 92) who was the patient and was sitting on the exam table, an elderly man (he looked to be mid to late 70’s) and an elderly woman who was severely hunched over clutching a cane. The patient was the hunched woman’s mother who lived with her and her husband. The husband referred to the patient as Mrs. Olsen (not Mom or mother).
I introduced myself to the three of them. I asked the patient what occurred to have her come into the clinic that day. She said she felt tired and a little short of breath. The man said she had been feeling and looking worse for several days. He also pointed out that the patient had developed swelling in her feet and ankles.
I asked about the patients past medical history, her medications and a review of systems. I then examined her. She had jugular venous distention, an irregularly irregular heartbeat at 120, crackles in her lungs half way up and pitting edema in her feet and ankles. She was clearly in congestive heart failure (CHF) most likely due to her irregular heart rhythm. I did an ECG. She was in A-fib with a rapid response rate. I had the nurse draw a CMP and thyroid function tests. Being 92 and the degree of heart failure, I believed she needed to be in the hospital for a work-up (like, echocardiogram) and treatment for the A-fib and CHF.
I advised the patient and her family that I thought she should be in the hospital for a couple of days to improve and stabilize her condition. The patient didn’t want to go into the hospital. She was fairly adamant about this. Her son-in-law tried to convince her. I stepped out of the exam room and asked my nurse to contact our main hospital to get an inpatient bed. I also had a full schedule of patients to see every 15 minutes. I saw a patient then went back to the 92 year old patient’s room. The first three times I did that, she was still not wanting to go to the hospital. The fourth time, she said yes!
In the meantime, my nurse had contacted the hospital and was told the ER and hospital were on divert, a Code Black! They suggested we contact the out-of-network (for this patient’s insurance) hospital in our city, so, the nurse called there and, of course, they were happy to take her. I was working in a capitated medical group at the time and this would mean a huge medical bill for the group. The cost of out-of-network hospitalizations was clearly communicated to us by the administration.
I thought I had a successful brainstorm when I thought of a secondary in-network hospital with a 30 bed medical unit. The patient didn’t need an ICU, so that would work! I personally called the hospital and got transferred to the medical unit. The nurse manager said they had a bed and could easily take care of the patient but, she didn’t have the nursing staff to cover the empty beds they had. They were short staffed!! She declined accepting the patient!
I then remembered that the medical group had just started a cardiology clinic in the same building as our clinic. I asked the nurse to see if I could talk to a cardiologist. Since the clinic was new, they weren’t very busy and I was pleased when a cardiologist actually showed up, in person, at our clinic pod. We went over the ECG, the patients history and meds and her physical findings. The cardiologist turned to me and said, “You know, we could probably treat her as an outpatient.” It wasn’t the best solution, but, trying to balance the patient’s wishes (she really didn’t want to go to the hospital), the odds of success of and outpatient treatment plan and the cost of the out-of-network admission, we decided to try the outpatient approach. The cardiologist outlined the care plan. I was a little nervous about it, but I decided to try it.
I went back into the patient’s room and had to tell them that I couldn’t get her into the hospital because of the Code Black and lack of staffing, but that I had consulted with an on-site cardiologist who had given me an outpatient care plan; were they OK with that? The patient was very happy about it. The daughter and her husband said they were willing to try it.
I wrote out instructions and prescriptions. The one thing that worried me was, it was a three-day Christmas weekend and I couldn’t get her re-checked for four days, the current day being a Thursday. The patient and her family left and I finished clinic.
The next day I was back at my physician executive job in an office at the health system’s main offices. I couldn’t get that 92-year-old patient out of my thinking. At noon I called the pod clerk at the clinic and asked her if she could give me the patient’s telephone number so I could call and see how she was doing. I got the number and called. The son-in-law answered. I asked how Mrs Olsen was doing; he said she seemed OK. Had they gotten her medications? Yes. Had she taken them? Yes. Was she having any trouble with the medications? No. I then told him I would like to come to their home the next day (Saturday) and check on his mother-in-law. He said, “Really, you would do that?” I said, “Of course, she could have been in the hospital. Some medical provider should check on her.” He said that would be great. I asked for their address. He told me their address. I was floored! They lived one block away from me! This would be the easiest house call I ever did! I told him I would be there at about 10:00 the next morning.
I walked over to their house the next morning. The son-in-law let me in and ushered me into kitchen. He called down the hall for his mother-in-law. She didn’t come out. He called for her again saying, “Mrs. Olsen, your doctor is here!” We waited again and about five minute later she came wheeling down the hall in a wheelchair.
I examined her. Her heart was in normal sinus rhythm. Her lungs had only crackles at the bases. There was only about half the swelling in her feet. She was doing a lot better. I told her she was doing fine and left. I went back the next day and she was doing even better. She was out of the woods for that episode. I had booked her an appointment with her PCP for December 26th, so, I was sure she would do OK. That’s the last time I saw her.
About two years later, my wife was walking our dog one morning when she ran into Mrs. Olsen’s son-in-law in his driveway. She asked how Mrs. Olsen was doing. Sadly, he said she had passed away about six months earlier. He told my wife he had to tell her a story that he told at her memorial service.
It turned out that Mrs. Olsen was on the telephone with a friend in the state capital 60 miles away when I visited her on that Saturday. When her son-in-law called down that her doctor was there, she said to her friend, “Alice, I have to go, my doctor is here.” The friend said. “What, you have to go see a doctor?” Mrs. Olsen said, “No, my doctor is HERE! In my house. He came to check on me.” The friend said, “What?!? I’ve had the same doctor for over 30 years and he’s never come to see me in my house!” Mrs. Olsen said, “You haven’t got the right doctor!”
Eighteen months later, Mrs. Olsen fell and broke her hip (or her hip broke and she fell to the floor). The ambulance was called and she was transported to the Emergency Department of the main hospital. They put her in a room, put in an IV and took her vital signs. They sat there for hours without anyone coming back into the room. After about six hours, Mrs. Olsen looked over at her son-in-law and said, “I don’t think we have the right doctor!”
Unfortunately, Mrs. Olsen never made it out of that hospital alive. I wish I had known she was in there, I would have visited her. She was quite the character!