The decisions we make have, literally, life or death consequences.
There’s a reason hindsight is 20/20 — we look back on a situation with the outcome
already known, and know precisely what we should have done to achieve the best results.
In most situations in our lives, hindsight doesn’t matter, but physicians have the
unique privilege – and responsibility – of knowing that decisions we make have,
literally, life or death consequences.
An elderly man has a Transient Ischemic Attack (TIA), but his denial delays transport
to the hospital. Once he arrives, the ER doctor doesn't refer immediately for definitive
treatment – and the once-vibrant patient suffers a devastating stroke.
Ten percent of people suffering a TIA will suffer a stroke within the next 90 days.
Half of these strokes will occur within the first two days.
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See the disease process from your patient's point of view
As a physician, one of your most powerful attributes is compassion – empathy in
action. Of course, to be a good doctor you also need skill and knowledge. But empathy
– seeing the disease process from your patient's point of view – creates a return
that delivers more than you may think.
When we care, we pay better attention. Not only do we give more effective medical
advice, we also prevent the number one cause of medical malpractice cases: discontinuous
care.
I've practiced family and emergency medicine in both rural and urban centers. Over
the past ten years, I've also been the in-house medical consultant at a well-known
personal injury firm, reviewing cases and advising attorneys. The following parallel
real-world scenarios illustrate the case for compassionate continuous care — to
the tune of $3.4 million.
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Henry
Henry was 71 and had been retired for a few years, but still golfed three days a
week, read the Times every day, and loved to travel in Europe. He woke up “feeling
funny” early Saturday morning. He noticed that his thinking was fuzzy, and he couldn’t
access the right words to describe his condition. Sarah, his wife of 46 years, was
asleep beside him. Henry didn’t want to alarm her, so he rolled over and tried to
go back to sleep. No dice – Henry knew something was wrong and, although he didn’t
want to admit it, he was afraid he had suffered a stroke.
After lying awake for an hour, Henry woke Sarah. As soon as she heard him fumbling
for words, she called 911. The ambulance crew arrived four minutes later and transported
Henry to a community hospital in northern Michigan. Henry was examined by Dr. A,
one of the local family physicians who staffed the hospital’s emergency room. By
the time Henry arrived at the ER, he was beginning to find the right words. Within
an hour, he was communicating normally.
Dr A performed a history and physical exam, finding only expressive aphasia that
had completely resolved while Henry was still in the ER. (Henry’s cardiovascular
exam, including auscultation of the carotid arteries, was unremarkable.) Dr A ordered
a head CT, which was read as normal. Blood work and EKG were also normal. Ultrasound
was not available.
Dr A discharged Henry after four hours in the ER, and set him up for follow-up visit
the next week by the local neurologist. Sadly, Henry suffered a massive stroke the
following day, due to a left carotid artery plaque that embolized to – and blocked
– Henry’s left middle cerebral artery, permanently injuring his left temporal lobe.
Henry survived, but only as a shell of his former self. No more rounds of golf;
no more trips to Paris with Sarah. He was paralyzed on his right side and mentally
incompetent.
Sarah was understandably devastated and extremely upset, but because she had no
real relationship with Dr A, she was also vengeful. In court, the jury awarded $3,400,000.
The insurance company settled after trial for $2,500,000.
Martha
Martha's story is similar, but has a different ending.
Martha and Chuck had been married for 38 years. They were at an annual Labor Day
barbecue in their northern Ohio neighborhood when her left arm went suddenly numb
and weak, causing her to drop her plate. Chuck called an ambulance, which arrived
in five minutes and transported Martha to the local community hospital, where she
was treated by Dr B.
Dr B suspected a stroke and performed an appropriate history and physical exam,
identifying an enlarged and tender right calf (due to a fall the previous week),
as well as a previously undiagnosed cardiac systolic murmur. The rest of the exam
was normal, except for a weak left arm. Over the next two hours, while still in
the ER, Martha’s left arm strength returned to normal.
Dr B diagnosed Martha with a TIA (transient ischemic attack), due to a deep venous
thrombosis of her right calf deep that embolized to the right side of her heart,
passed through a previously undiagnosed ventricular septal defect, and finally lodged
in her right middle cerebral artery.
Knowing the significant risk of stroke after a TIA and concerned that Martha face
this risk, Dr B transferred Martha emergently to a nearby trauma center. She was
quickly diagnosed and treated medically and surgically and continues to enjoy holiday
barbecues with Chuck.
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