Death by Follow-up Appointment

It’s hard enough to get an appointment with a primary care physician, but when that primary care physician recommends your seeing a specialist, getting that appointment can get dicey. But what happens in the emergency room (ER)?

Thus my interest in the recent Idaho Supreme Court decision Morrison v. St. Luke’s RMC.

A patient was seen in the ER for chest pain and determined, according to the case record, not to have been having a heart attack. However, the ER physician did recommend the patient see a cardiologist for a consult. The patient was unable to get an appointment with the recommended cardiologist for a month. With pressure from the patient’s family, that time was shortened to two weeks. The patient died of a heart attack before he could make it to his two-week appointment.

Admittedly, there’s a lot we don’t know here. While the patient may not have been having a heart attack when he presented to the ER, how was this determined? If by testing for troponins, was there subsequent troponin test to check for change. The court records do not give these kinds of details.

We really don’t know the reason the ER physician recommended the patient see a cardiologist. If we knew the reason, we might have some notion of why the ER physician apparently didn’t make sure that the patient got to see a cardiologist quickly. Whatever the reason, the ER physician did not make a required “urgent” chart notation to indicate to the cardiologist’s receptionist that this patient needed to be seen sooner rather than later. Without that notation, the cardiologist’s receptionist refused to release one of each day’s two “emergency” appointments to this patient.

The patient’s family lost this court case for any number of reasons. But common sense supports the notion the ER physician and the cardiologist’s gatekeeper receptionist were seriously delinquent in how they managed the follow-up. Even without the ER physician’s “urgent” notation, the receptionist should have asked enough questions to realize this patient had very recently been in the ER for chest pain, always a red flag. If the receptionist had any doubts, she could have checked with the cardiologist. Or she could have checked with the ER physician. There are a lot of shoulds here, the lack of which likely resulted in this patient’s death.

When our practitioners want to refer patients to a specialist, they call the specialist. The specialist can decide how quickly to see the patient. That may be the same day, or if a Saturday or Sunday, possibly on Monday. Sometimes this means the specialist meets the patient in the ER. Sometimes this means the specialist gives the primary care practitioner directions for the patient’s care in the hospital until the patient may be seen. Sometimes this means the specialist has the patient sent home for the weekend and arranges for the patient’s care on Monday.

No patient should leave an ER without a timely appointment with a specialist when the ER physician recommends the patient see one.

To me, the disturbing elements in this failed malpractice suit are many. First of all, the “team” approach to healthcare which has become so popular can easily overlook this kind of failure in patient follow-up care. More importantly, the “team” approach divvies up the responsibility for care among several providers. It’s harder to put the responsibility for bad outcomes on several “players” than it is on one responsible person. There are simply more cracks for vital information to fall through.

In this case, the Supreme Court of Idaho felt satisfied that the ER physician and the cardiologist’s receptionist had med the “standard of care” for follow-up. If this is the “standard of care,” it’s time for a new protocol.

Furthermore, in all of The Centers for Medicare and Medicaid Services (CMS) attempts to document quality of care and make physicians responsible for “quality” measures, I strongly suspect nothing like being sure ER patients get timely follow-up for recommended specialist appointments is even measured. Is anyone bothering to see whether the “follow-up” papers handed to patients as they leave the ER are actually acted upon? To see if possibly someone has died for lack of timely follow-up appointments?

I strongly suspect the bad outcomes from the lack of timely follow-up for ER patients is huge. The death of Rory Staunton comes to mind. When the practice of medicine becomes primarily evidence-based check boxes, physicians lose the opportunity to learn that large area of practice which doesn’t fit the current health care buzzwords. Physicians also lose the opportunity to learn that listening to patients often reveals what’s really wrong. There is no real evidence to support the notion that the 997-page Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) saves money. Only that physicians, especially primary care physicians, will be paid less for making sure their ER patients get timely appointments with specialists.

It’s time those without medical degrees stop practicing medicine in the name of saving money (with a hand wave in the direction of improving the quality of the care) and let physicians do what they do best— provide quality, individualized health care to patients they know and care about.

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