How far do you go for Patient-Centered Care?
By Stephen Dahmer, MD
We are a new practice in downtown Brooklyn part of a new company trying to revolutionize primary care. “We” because of the team approach we offer, providing high-quality, patient-centered care that introduces patients to a squad of health stewards extending traditional medical care far beyond me as the doctor. Each member of the team is as valuable as the other. But, these are all topics for separate essays. Today we want to tell you about a specific, small revolution and how it relates to cost, but far more importantly how it related to value for our patient.
It was his second appointment at our clinic. During his first he was pleasant, engaged and excited about the team-approach. We discussed his history of well-controlled hypertension and elevated cholesterol during a “routine physical”. This second visit started when he emailed his health coach early that morning about a vague abdominal pain that wasn’t “terrible right now but but my lower right abdomen is very sensitive”. We told him to come directly into the clinic and, in the future, not to use email for urgent matters. He was our first patient at 9am and his was a classic case of appendicitis. Pain initially periumbulical, now right lower quadrant, 7-8/10 in severity, asociated with nausea and with tenderness at McBurney’s point on exam. The wheels were quickly being greased for the knee-jerk transport to the Emergency room like we had done so many times before. In the organized chaos of that moment, we had a creative thought: what if DH didn’t have to go to the Emergency Room?
We should clarify this thought with a disclaimer. Although team-oriented and revolutionary, we are no less devoted to the distilled version of the hippocratic oath: “above all, do no harm”. Although forward thinking, in no way would we ever take chances with a patient’s life. Yet, despite our evidence-based approach to health care and board certifications, we struggle against inattentional blindness and towards innovative medical decision making while still keeping the “patient as center”.
We acknowledged the uncertainty of a new approach to an old problem and we did what we usually do in these situations. We talked it over amongst ourselves and made certain there were not any absolute objections. We then walked back into the exam room and asked the patient. We explained that this is not usual practice. We explained that, not being standard of care, there are potential risks involved. We also explained the potential benefits. We discussed in detail a plan including oral antibiotics, stat blood work, an EKG and getting him directly to the CT scan and surgeon’s office all without placing foot in the emergency room. That night he wouldn’t be in the hospital, but at home. He would be given pain medications, detailed explanation of red flags, and surgery would be done first thing in the morning. Throughout the night he would have 24-hour phone access to us and, if the situation worsened, he would have a copy of his CT and his choice of multiple hospitals on the Upper West Side of Manhattan to report to where we would help facilitate his admission.
He told us he would prefer, if at all possible, to avoid the Emergency Room and could call his girlfriend to accompany him throughout the night. He told us that if we were comfortable with the plan, then he was as well. He also stated he had financial concerns and a $10,000 deductible. After speaking with the surgeon, the plan was solidified and cost was estimated at $4,100. Detailed instructions were repeated on warning signs of worsening illness. The patient’s EKG was normal, his vital signs were stable, his labs were reviewed and ciprofloxacin and flagyl were started by mouth. The CT scan revealed acute appendicitis, the surgeon saw the patient in person in his Manhattan office and surgery was schedule for the following morning at 7:30am at an outpatient facility.
After a check-in with the patient that afternoon everything seemed fine. His pain was controlled. He was resting at home with his girlfriend. He was comfortable with the overall plan and he knew what to look out for if things seemed to be going in the wrong direction.We didn’t hear back from him until 3:14am that night. His pain was worsening, yet he still didn’t have a fever and overall he felt “ok”. We calculated from his medications that he could increase, even double, his pain medications and decided to see if that would help. This was the only step above and beyond our normal primary care duties. If he had been sent to the Emergency Room, we would have never gotten this page. By some estimates, this single page could have a value in the range of $100,000. Hence the title of our essay. Very likely exaggerated and inflated, but we wanted to get your attention to read the article.
We didn’t hear back from him until the following morning. He was at the outpatient surgical center and all was moving forward as planned. The operation was a success and later that day he was home. We were in contact both via phone and email and he wrote: “Hi All, That was necessary surgery! I’ve what I assume to be the usual post-op discomfort but feel much much better than I did before. Will keep you all posted. Thank you for your care.”
4 months out from the operation, our patient is still doing well. By the latest count he saved “the system” somewhere between $10,000 and $132,000. He saved himself approximately $6,000. In retrospect, it may have been prudent for him to sign a waiver to signify the seriousness of his choice. It took over 30 minutes to get the oral antibiotics from our pharmacy across the street. We now stock them in our clinic at a cost of around $5. Explaining the maximum dosage for pain meds may have saved the 3am page. Above all, we’re left with one burning question. Did we provide the best possible care for our patient? Like so many cases we see, there is no right answer. We’re putting the case out there to get more thoughts. There was the potential for rupture and sepsis. We acknowledge this. The patient was aware of this. We are having trouble finding numbers of actual cases, but recent evidence seems to suggest against a high probability. One the other hand, we potentially saved our patient from complications that occur every year in hospitals. There also exists the possibility of having prevented him a nosocomial infection by treating him outpatient.
To conclude, we would like to share our patient’s reflections: “Undergoing this would have been difficult for a single person. You need a helper. You’re in pain and not 100% mentally so following instructions, etc., is more difficult. If the doctor already knows the patient well that’ll help; he’ll have a sense of what kind/level of care the patient’s likely to prefer. I can’t evaluate how smart dealing the my appendicitis this way was medically but personally I’m happy with it. I liked being able to avoid the ER and the hospital. And cost was a major concern too since I have a $10,000 deductible.”
Now, we would like to hear yours.
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Stephen Dahmer, MD is a family medicine physician at Collective Primary Care in Brooklyn, NY and a contestant in 2013 Costs of Care Essay Contest.