No Better

“No better” was the message I got last week about a sore toe, a stubborn cough and a case of C. Difficile diarrhea. All three messages were false alarms, misleading missives, inadequate information or whatever you want to call it.

After a few more questions, all three patients turned out to actually be doing much better than the messages suggested.

The octogenarian with the sore toe, which looked like gout to me, told me the exquisite pain she had experienced from the lightest touch was gone, the throbbing had subsided, and now there was just a strange itching deep inside her toe. The swelling was almost gone, and she didn’t even flinch when I squeezed her toe. The two days of prednisone I had prescribed really seemed to have helped her. And, her uric acid level had come back elevated.

The man with a cough back in April had actually almost stopped coughing after a ten day course of antibiotics for his cough, sinus congestion and postnatal drip. But his symptoms had gradually started to come back. He hadn’t refilled his prescription as I had told him he could, but decided to give it more time. Now he was almost back at square one. I told him to take another round of the antibiotic and expect to see him do well.

The poor woman with clostridium colitis had improved significantly, but wasn’t quite back to normal. Her probiotic order had stopped when her metronidazole stopped and she turned out to have a fondness for tall glasses of cold milk. I had her restart her lactobacillus and give up the milk, and within two days her stools were formed.

In all three cases, one or two simple followup questions provided information that the prescribed treatments had actually worked fairly well. But in all three scenarios, either the patient or the person who took the message seemed to have an all-or-nothing mindset, almost like a “true or false” quiz, or “complains of/denies” click boxes in our electronic medical record.

This is a problem in healthcare today: Information is expected to be “discrete”, “structured”, or straightforward. But people and diseases are usually more nuanced than that. And without the nuances provided by a real patient narrative, we risk making deleterious treatment decisions.

Medical practice is not usually so algorithmic that simple yes or no answers can guide our treatment decisions. One person’s yes is another person’s no, depending on their expectations and a host of psychological factors.

Our job is to listen to the narrative and, only then, decide whether to follow the “yes” or the “no” arm of whatever algorithm we are trying to apply.

In this era of EMR click boxes and team based care, there is a real danger of seeking simple answers without listening to patients long enough to understand what they are trying to tell us.

We learned this in medical school and residency. EMR people and office staff didn’t. We need to pause and think like doctors before we give knee-jerk responses to seemingly simple messages.

5 Responses to “No Better”

  1. 1 jmccarty3 June 7, 2016 at 11:22 am

    I hear this all day long in my dermatology practice. The rash may be 95% gone, but the patient complains that she’s “not any better at all.”

  2. 2 vanslix June 7, 2016 at 12:40 pm

    All too true. Reminds me of the old adage about carpenters charging too much. All they do is hammer a nail in. But it’s knowing where to place the nail that counts.

  3. 3 Aletha Cress Oglesby, M.D. June 7, 2016 at 2:10 pm

    Everytime time I read one of your posts I wish you had a “like” button on this blog. Messages can be so misleading; sometimes, even when I talk to the patient on the phone, the story is completely different when they relate it in the office. In addition to the message “not better” is the “worse” message. Worse how? I need to know. And most frustrating of all is the “better” patient, who then complains of being “worse” once back in the office.

  4. 4 meyati June 7, 2016 at 4:06 pm

    I blame the nurses big time- I actually dealt with this problem yesterday. Too much power and descretion is given to the nurses that answer phones, Emails, and EMR messages.

    Yesterday. Rare cancer under the nose-in remission. Message–Getting a hole in the bone at the cancer site under my nose. It seems to be causing extra pain. Your Dr. noted bone change in Feb, and asked if I was diagnosed with a rarer varient. I did not have that diagnosis. I get my scan-date a few weeks away. Appt. with Rad ONC 7 days later. I see your Dr a few weeks later-date given. I want doctor to know this before visit.

    I don’t have a fever, the skin texture/hasn’t changed, etc.
    OK, in 4 years this is the first time I contacted the office for anything, except to say– the LAB dosen’t have the Dr’s. order or to reschedule.

    The first answer was: I don’t understand your message. I asked what part of a hole in the bone can’t she understand. If I knew what it was, I would be a doctor. Your doctor is labeled a oncologist that specializes in rare cancers-I have a rare cancer. She replied-I decided that I’ll talk to the doctor about this—Do you think? I finally received the message that the doctor was apprised of the situation.

    I know this isn’t a blockage, losing lots of blood, turning green and purple, but holes in bones should be somewhat of a concern. This doctor does lots of research, if given the chance.

    How about Pasteurella multocida? Clear fluid or pus coming out of each puncture. The ER didn’t do it right-I was in 20 minutes after the bites. I didn’t want to pay out a large co-pay for that again-I called that ER as worse than useless before the dog bite. This was 2 weeks after cancer radiation treatment ended.

    I called my PCM 4 times the first day–the nurse asked if I had red streaks going up my arm. No–Good-bye. The next day, I called every 20 minutes. same conversation. The 3rd day- the clinic desk receptionist went to the doctor herself and told him in person. Three hours later, I was hooked up in a surgery ward to pain killer, IV fluid, and bags of Augmentin. One nurse fainted when the towel was taken off and clear fluid and pus went all over.

    Now, my Radiology oncology nurse-the hole in the chin–I’ll let the doctor know immediately, and make sure the scan orders completely cover that area. and address your concerns. I had a grandson, who hadn’t urinated over night, and he really hurt and had a high fever. My daughter had office visit and hospitalization insurance-but not ER coverage. After 2 hours of calling the clinic office, the receptionist went and talked to the doctor herself. The nurse never did return the phone call. She was in the office-whining that she thought it wasn’t important- that was over 20 years ago. My grandson did really have a temp of 104.

    I know that so many people claim to have this or that-whatever- but there needs to be some phone triage and part of this should be based on frequency of calls about a certain concern, ER or UC visit for this concern, 104 body temp,, about ordering a past due annual test when the PCP is gone. Yeah, the nurses told me to go to UC. I did go- and waves were created-not for my PCP–it wasn’t her fault at all.

  5. 5 drd11 June 11, 2016 at 6:52 pm

    In the good old days it was: “Treat To Diagnose”.Today it is: “Diagnose to Treat”. What dose that mean?. It means that in the :Good Old days, there was only one antibiotic and one aspirin.So,then, the patient was treated immediately, without running so many tests(And expensive ones!).Not the mention the time wasted. By the the time the real time, the patient is treated, he is already Septic and wasted: Physically and economically.
    Maybe we should change: Diagnosis and Treatment, to treatment and Diagnosis.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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