We can do better

A few weeks ago, I had a really bad sore throat after a simple cold. It went on for about ten days. It was Friday, I was tired of the sore throat and I was afraid that if it won’t go away, I will be in pain all week-end.

I called my primary care physician/provider (PCP) office and begged for a same day appointment. They asked me how soon can I get there. 🙂 “20 minutes”, I said. “We’ll see you in 20 minutes”.

I got there, they did the registration quickly and I was “roomed” (weight, blood pressure measurements, a few questions from the physician assistant – PA). I was going to see the nurse practitioner (NP), not my normal doctor, which was perfectly fine for me.

The NP came in, asked a few questions about my cold, checked my lungs, ears, throat, and did a Strep test. She mentioned giving me Amoxil. She recommended lots of fluids, Tylenol, Advil, Motrin round the clock and Amoxil for ten days even before getting the results of the Strep test and call back if not OK by next week.

I was thrilled to get my antibiotic prescription, did not ask any questions and left. I started taking the Amoxicillin, and 24 hours later I felt better. A week later I was as good as new.

So how can we do better?

Reflecting back at the visit, while working on becoming an e-patient (engaged, empowered, enabled),  I realized that from the perspective of me as a unique individual, this appointment was bad in many ways:

– The meaningful use certified EMR did not appropriately flag the NP that I have ulcerative colitis UC (extra precautions were needed because antibiotics could cause flares) and that I should not take NSAID (like Advil).

– The NP completely ignored the fact that I have UC – we should have discussed if I really want to take antibiotics considering that I could get a flare (I am well aware of that and yes, I hurt so bad, I really wanted something). She should not have mentioned Advil – I’d like this to be written really high in my record, right under the drug allergies!

– I did not say anything either. As an engaged patient, I should have raised these issues. I was in a hurry, I knew what I want and I was pressured by the hurry in the office, and felt guilty and grateful about coming in on such a short notice.

What do you think? What should an e-patient do? How do we mindfully communicate and educate?

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About Ileana Balcu

Passionate about healthcare, participatory medicine, e-patients, databases, IT and Health IT, social media, communication, teams and yoga. Proudly volunteering for the Society for Participatory Medicine http://participatorymedicine.org #s4pm

Posted on October 17, 2012, in Uncategorized. Bookmark the permalink. 12 Comments.

  1. It’s incumbent upon us to fully participate in our care, unless we’re unconscious. I understand why you might not have brought everything up while feeling like crap and hoping to get a fix, but not talking about your UC/antibiotics/Advil issues was a dropped ball on both sides of the conversation. It *should* be at the top of your chart and on the EHR in-room screen for any visit, and you *should* push back on antibiotic scrips and Advil recommendations to make sure you’re not gonna get even sicker.

    That said, the fact that you’re asking this question reveals you to be an e-patient =)

  2. Wow, have we all been there and done this! You think of all sorts of things when not ill and at home, but you see those white coats and it all goes out the window (especially if the white coat in question seems pressed for time). I am so with you on wishing for the day where our health data is kept current (at both ends) as easily as our checkbooks!

  3. Ileana, this is really an important question for all of us. I’ll be anxious to see if you have new thoughts about this after reading Peter Ubel’s book. Not only do we need to be well-informed, but both e-patients and (e-)providers need practice and coaching to do these interactions better.

  4. I’m assuming your interest is in discussion of the interaction and not the medical care itself?

    As a clinician (family doc), part of my DNA coded ritual with every visit is to look at the problem list, medication list and allergy list. Exactly when and how this is done varies some according to context. With patients I know well (or whom I have seen a few times and suspect the patient assumes I know them well), it is usually couched in terms like “Lets quickly make sure your list of problems and meds is up to date.” If it is a patient I am seeing for a colleague, I will often say something like: “Let’s take a look at your clinical lists to make sure I don’t miss something important.”

    Assuming the UC is on the list (if it isn’t, this is not an EHR problem anymore), this is what triggers the conversation about how active it is and the questions about previous problems with medications. I can also say ‘According to this, you have taken x and y before. Did you tolerate them?’

    My clinician self says that I am open to the patient raising issues like this…but the patient may be ill/scared/confused/off balance in my backyard, so I cannot demand that the patient initiate this.

    Now, changing hats and assuming the role of patient. When my wife and I attend visits together, we ask ‘How will this impact the RA?’ or ‘Does it matter that the Rituxan is scheduled for next week?’ or ‘Should we check with the rheumatologist before we do this?’ We feel that, by asking, we have the opportunity to frame the discussion some and offer education.

    On another level, you said you knew what you wanted. I wonder. Did you want antibiotics? Or did you want to feel better? Or did you want information about how long before you would feel better and reassurance that nothing bad was happening? It is hard enough to help people when I know what they want. If I don’t know what they want, it is a real crap shoot and can lead to crap for care.

    Peter

    • Peter,

      Lots of great ideas here. I will write an answer on the blog and list. Many thanks! Exactly the kind of feedback I was hoping for!

  5. Ileana, all of us forget things at the sight of the white coat. But I also think that mentioning the reactions was important for her, for pointing out problems in the medical record and, well, because a line of reasoning that goes, “No harm, no foul” in this type of encounter makes me uneasy. Although, I guess, “Sure, if I’d followed their advice it would have sent me to the hospital, but I knew not to do it” is certainly an example of empowerment. 🙂

  6. I’m an internal medicine resident and aspiring primary care doc…and first want to thank you for sharing your experience! I think you are absolutely correct in wondering whether you should have asked about your UC…In a world of MinuteClinics and off the shelf strep tests the only real value add of going to your primary care clinic for urgent care is the ability to evaluate your complaints within the context of your known medical history, allergies, as well as preferences/ goals in regards to wellness.

    Re: antibiotics, I’m going to assume the provider used a Rapid Strep testing kit (but should have explained this too you) – you can actually buy them directly from Amazon yourself 🙂

    http://www.amazon.com/Rapid-Response-Strep-A-STR-15S25-Strips/dp/B001DD04SQ

    • Connie,

      Thanks for your comment. I did not know that they have rapid strep tests over the counter, which is funny because the NP didn’t have the rapid one and sent the test to a lab. Once again it pays to be an informed consumer. I am reading Robert Centor’s blog and I think I remember him saying that if our patients do not get better after a week or so and still have a sore throat, we should try antibiotics… I can’t find the exact quote, but he has a bunch of posts on sore throats if anyone cares to look. http://www.medrants.com/?s=pharyng

      Once again, I did not want to get into the nitty gritty of things, but doing a test that had no influence on the prescribed treatment was icky to begin with.

      Thanks again,
      Ileana

  7. Re Connie’s comments that the real value of going to the primary is for the evaluation within the known medical history etc. In my opinion, a true Epatient will have all his records in hand, even in a paper bag, rather than risk the possibility of no one reviewing the records or having errors in the records. Think of the mom who carries immunization booklets, or a packet of 3×5 cards for her chicks. Don’t want to forget who is allergic and who is overdue for a check of the rash or for whom to make the next appointment.

    • I agree, Peggy, but there’s also value in the doctor looking at a familiar organization of facts, as long as the facts are in their face… If not, which seems to be the case here, your own records are mandatory.

      I have a simple history, so I’m thinking write a letter size page with a big Ulcerative Colitis and a Do not prescribe NSAID on it. 🙂

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