The Doctor Weighs In

By Maggi Cary MD, MBA, MPH

Bob and Lara were my landlords, in their 60s, and lived across the nearly-two-lane road in the house they built over Adobe Canyon Creek in Sonoma County, California.

I was Bob and Lara’s doctor—not in the come-to-my-office sense, but in the I’m-the-only-medical-person-in-the-family sense.  Bob developed a Dupuytren’s contracture, which is where a finger, or fingers, is drawn down toward the palm.  The connective tissue thickens and shortens, so moving the affected finger(s) is difficult.  The treatment is surgery and I recommended one of the top plastic surgeons in town.  Another friend did Bob’s anesthesia, blocking the nerves leading to the hand, much as dentists block nerves in your mouth, with Bob awake during the operation.  I assisted with the case and we all—patient, surgeon, assistant and anesthesiologist—chattered together during the case, sharing jokes and laughing.

Bob’s hand healed well and he would often hold it up, showing the scar and proudly saying, “Maggi is my doctor.”

Lara and I were particularly close and she listened to me in good times and bad.  She saw me through each of my parent’s deaths, medical residency, my first years of medical practice, moving to Denver and a devastating break-up.  We kept in touch through telephone calls and writing.  I looked forward to each handwritten letter.  Lara had been a looker in her younger years and Bob had swept her off her feet as a handsome and cosmopolitan young man from an old New Orleans family.  

Each time I visited the Bay Area from Denver I added extra time to drive over the Golden Gate Bridge to visit them.  By the time I turned the car around in the circular driveway Lara and Bob had stepped off the porch to greet me.  Sonoma County always felt like home.  

We hugged, walked up the three stairs to the threshold and sat in the living room.  After a brief catch up, Bob drove Lara and me to the local family-owned restaurant.

Bob’s eyesight began failing from macular degeneration, a common cause of age-related blindness where the macula, or central retina, degenerates and so cannot capture images to send to the brain to interpret. Twice he nearly had a car accident as he turned onto the main highway.  Lara was getting increasingly forgetful and was anxious about becoming senile.  Their only child and his wife, Glyn and Jane, coaxed them to move into transitional housing to be near them, about 120 miles away.  Bob and Lara had lived in their house for decades and left the area and their friends reluctantly and with many tears.

I continued my tradition whenever possible, visiting Bob and Lara and staying with their son and his family.
Jane told me Lara could scarcely contain herself when she knew I was coming to visit.  She was happy from the time

I called to let her know I was coming until long after I departed.  I have often thought since then of the power in spending time with people—in just showing up.

Our roles began reversing.  Lara and Bob had always looked after me from afar and now I was looking after them, adding however I could to Glyn and Jane’s excellent caregiving.

Lara’s “forgetfulness” was early dementia.  She steadily declined from independent living in their transitional housing facility through daily assistance to needing more care than the facility could provide.  She had to move to long term care while Bob’s macular degeneration progressed to where he could no longer read.

The closest facility for Lara was two hours and three bus routes from the apartment she had shared with Bob.  Bob, virtually blind, visited her once or twice every day.  Lara often did not recognize him, yet he stayed, talking with her and holding her hand.  

Bob became ill with a chest infection and was treated as an outpatient.  After treatment he was admitted to the hospital in a confused state.

“I see spiders,” he said to Glyn as he picked at the air from his hospital bed.

Glyn told Bob’s doctors he had been a perfectly coherent, spry 88 year old before his hospital admission.   The doctors seemed indifferent.

As often happens with old people, after his acute hospitalization, Bob was transferred to a nursing home.  When he arrived the staff immediately returned him to the hospital, saying he was too sick to be in a nursing home and suggesting further evaluation and treatment.  

I flew from Denver to California to be with Bob and his family and see what I could do to sort out Bob’s medical care.  He died before I got to his bedside.

On the surface, this might seem to be just another death of an elderly man.  Often when elderly spouses are separated one will die.  As I sat with the family the day after Bob died, with his granddaughter Ann, in her final year of medical school, she and I reconstructed the details of Bob’s final days.

Bob’s physicians had started him on antibiotics a few weeks before his death.  As we listened to the course of his illness and the timing of events Ann and I began asking questions.

“Tell me again how he was acting,” I asked.

“Bob was seeing people who weren’t there and talking nonsense,” Glyn said.

I recalled the spiders.  These hallucinations sounded like liver failure, usually caused by chronic alcohol use, but also caused by certain medications with a similar effect on the liver, especially in the elderly.  Bob wasn’t a drinker.

“Was he yellow?” I asked.

“Yes, at the end.”

Another sign of liver failure.  

“Do you remember what antibiotics he was taking?” I asked.

“No.”

“Was he getting regular blood tests while on the antibiotics?”

“I don’t know.  He had blood drawn when he was in the hospital.”

Too few facts, but Ann and I looked at each other.  I mentioned medication-induced liver failure.  

Ann nodded her head and said, “That’s what I’ve been thinking.”

As near as we could tell from the limited facts it appeared the antibiotics had damaged Bob’s liver, leading to his confusion, jaundice and death.  In general, medications are processed by the liver or the kidneys before being excreted.  Some medications have well-known side effects on the organs.  Specific antibiotics are notorious for this, especially in the elderly.  The standard of care is to check the liver enzymes in the blood.  If the levels are up, it means the liver cells are being damaged.  It was not clear to me Bob’s liver enzymes had been regularly checked.

It appeared to me his physicians paid no attention to Glyn and considered Bob to be a confused old man who was grieving over separation from his wife, perhaps even thinking him an old geezer not worth saving.  

A couple of days before Bob died his physicians recognized he was jaundiced—yellow because of liver failure.  Bob was confused because of the build-up of ammonia from his liver’s inability to process it.  Bob probably died of the side effects of medications toxic to his liver.

Had Bob been cared for by clinicians who remembered to check his liver enzymes, he might have lived through his illness.  His medications could have been stopped or altered when the liver enzyme levels were elevated.  Had Bob’s care been coordinated among his many physicians, both outside and inside the hospital, I don’t believe he would have died from this event.  He would have been alive for his granddaughter’s graduation, with honors, from medical school three months later.

Failing to check liver enzymes in an elderly patient on certain medications is malpractice.  “Old” and “done for” are not synonyms. Primum non nocerum—first, do no harm.

I moved from my fourth grade dream of being a small town family practice doc to working on national health policy so I might have a tiny role in fixing the broken healthcare system.  Through all my work in clinical care, regulation, health policy, public health and business, through my journey through nearly every component of the medical industry, it came down to my friend Bob and medical error.

Dr. Cary is Director of the Washington, DC office of the Institute for Medical  Leadership.

Lot’s of funny (and not so funny) news to share:

Musician canned for focus on the wrong organ.

A Catholic priest has removed his church's organist and choir director from her duties saying her sale of sex toys was not "consistent with Church teachings." Linette Servais, 50, played the organ and sung with the choir for 35 years. Much of her work as choir director and organist was done without pay. When her parish priest asked to meet with her, she thought it was to say thank you. Instead, she was told to quit her sales job with company known as Pure Romance or she would lose her position in the church.

Doctor rails against attorneys on his blog, not a good strategy when it is your own malpractice trial you are writing about.

As Ivy League-educated pediatrician Robert P. Lindeman sat on the stand in Suffolk Superior Court this month,
Dr. Robert Lindeman, aka "Flea"defending himself in a malpractice suit involving the death of a 12-year-old patient, the opposing counsel startled him with a question. Was Lindeman Flea? Flea, jurors in the case didn't know, was the screen name for a blogger who had written often and at length about a trial remarkably similar to the one that was going on in the courtroom that day. In his blog, Flea had ridiculed the plaintiff's case and the plaintiff's lawyer. He had revealed the defense strategy. He had accused members of the jury of dozing. With the jury looking on in puzzlement, Lindeman admitted that he was, in fact, Flea.

In the Creation Museum, it is all by the Book.

The 60,000-square-foot Creation Museum, which opened this week on 49 acres of lush Kentucky countryside, is the work of Answers in Genesis, a leader in the "young Earth" creationist movement. Unlike proponents of intelligent design -- who question aspects of evolutionary theory but may accept that the universe is billions of years old -- members of "young Earth" groups insist that the Book of Genesis is an accurate historical record.

Evan O'Dorney, winner of the BeeAnd finally, did you watch the National Spelling Bee on television? Medical words were the “makers and breakers” of the contest. Nate Gartke, an eighth-grader from Edmonton, Alberta, misspelled coryza, a word for the common cold – he added an “h” at the end. Evan O'Dorney, a home-schooled 13 year old from Danville, California correctly spelled serrefine, small forceps for clamping a blood vessel.

Pat Salber, MD

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This is an interesting story to follow yesterday’s post on supply-driven demand in healthcare. The results of a WSJ Online/Harris Interactive Health-care Poll are in and they show that many Americans don’t follow their doctors’ advice. It is pretty interesting stuff.

Seventy-two percent (72%) of folks polled answered “often” or “sometimes” to the questions “based on what you know or have heard, how often do you think patients who have medical conditions experience problems because of being over-treated, for example, by getting too many treatments or by getting more aggressive treatment than is appropriate.” Only 5% of people said it never happens.

Eighty-three percent (83%) of people said patients are often/sometimes under-treated. The poll did not ask how often the respondents thought people were treated appropriately.

Only 43% of people (down from 50% in 2005) were “very” or “somewhat” concerned about overly aggressive treatment. In fact, 57% said they were not very or not at all concerned about it. Hmmm?

Thanks, but no thanks.

The poll shows that:

• 27% did not fill a prescription given to them by their doctor
• 20% sought a second opinion because they thought their doctor’s advice was too aggressive
• 13% did not get a recommended diagnostic test.
• 7% did not get a recommended surgical procedure
• And, 7% of people changed doctors because they felt their doctor’s approach was too aggressive.

And, maybe they were right

Only a handful of people who chose to forgo recommended treatment experienced any negative outcomes as a result. Two percent (2%) experienced a new medical problem or complication, 2% required hospitalization, 4% lost time from work or school, 3% went to an ED, and 3% said their health got worse. A whopping 89% said nothing negative happened as a result of ignoring their doctor’s advice.

So why do these people think docs are overly aggressive?

More than half of respondents think doctors over treat patients because they are worried about malpractice lawsuits. Forty-one percent (41%) thought docs did it to make more money. Forty-four percent (44%) were less cynical about doctor’s motives. They thought doctors were overly aggressive to meet patients’ demands. Now, here is one that is really worrisome, almost a third thought docs were too aggressive because they received misleading information form the prescription drug or medical device companies.

So what’s a doctor to do? If you are less aggressive, you might get sued. If you are too aggressive, your patient might ignore you, or worse yet, find another doctor. And, what if you get it just right? What happens then? You might get thanked. You might get paid. And you might just feel good enough about what you are doing to get up and do it another day.