This is the first of two “horror stories” a colleague wrote for me(a stalwart fellow, who doesn’t tolerate fools gladly – but who is coy enough not to want to be identified).
50s something man with non-life threatening chronic shoulder pain presents to MWH & is admitted with "altered mental status, falling, trouble breathing". He is taking Opana (a long acting morphine preparation) & Methadone (both Schedule II drugs), Diazepam, Restoril, & a third benzodiazepine (all Schedule III or IV drugs*). Each of the 5 drugs alone might be the cause of all his presenting complaints, but the combination of all 5 would have to be considered as a primary cause for his symptoms. At discharge, his Opana dose was left unchanged, his Methadone dose was actually increased!, his Diazepam dose was increased, his Restoril was unchanged, and the third benzodiazepine was discontinued.
Error #1 - "altered mental status" is too non-specific, & an adequately trained health professional should know to differentiate it further.
Error #2 - In the Discharge Summary, NO justification whatsoever was given for raising the doses of Methadone and Diazepam.
Error #3 - There was no discussion in either admitting H&P or Discharge Summary that at any time his treating physicians considered that his medications might have been the cause of "altered mental status", falling, trouble breathing.
Error #4 - there was no suggestion that his physicians considered a need to decrease the dosage & number of his scheduled drugs.
His obituary was subsequently noted the following year - no cause of death given.
* Scheduled drugs are those deemed by the FDA and the Controlled Substances Act to be ones with abuse potential, but whose beneficial affects justify there being used in some situations, and with caution.
So this is one of those “how can the doctor be so stupid?" Type stories. But it also highlights some deficiencies of the system:
Diagnosis is absolutely fundamental to proper management and requires careful consideration and weighing of the evidence. But anyone who has to review hospital records is aware, very often the diagnosis is nothing more than some condition that will justify an admission and allow it to be billed, which means it merely has to be a valid ICD code. So the diagnosis that the patient is given is often not anything that contributes to what’s actually going on.
Communication between various doctors/providers looking after a patient is essential. The primary care doctor, receiving a patient like this back into his or her practice, needs to know not just the potted diagnosis (“altered mental status” – R41.82), but what lead to that conclusion. And certainly one would want to know why on earth the dose of the kind of medicine that likely caused the problem in the first place was increased.
Communication between doctors is meant to be improved by electronic medical records. But in some ways, EMR has made things worse. It’s an innovation that should, and likely will, improve communication in the long run, but they way it is now it’s all too easy to put in massive amounts of completely irrelevant information about the patient’s history and exam – which allows one to “up-code” and charge more.
But then any doctor/provider who is the recipient of such a record can’t see the wood for the trees.
Incidentally, drolly noting that this guy’s obituary appeared in the paper the following year suggests that maybe his overall care wasn’t all that it might have been.
At the risk of sounding like a broken record, the safeguard against these deficiencies of the system is to be medically emancipated. Be alert, involved and informed – that’s what Managing Your Doctor is all about.