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A safer encounter with the health care system

by Laura Nathanson

San Diego Union-Tribune
May 23, 2007

The message in the media is absolutely clear: We all ought to take a more active role in our health care. But these scary stories fail to show people how to do so, especially in the two areas most important to us: arriving at an accurate diagnosis and staying safe in the hospital.

Two recent books have (unintentionally) inflamed the public's frustration.

In his recent elegantly written best seller, “How Doctors Think,” Dr. Jerome Groopman advises that there's not much recourse for patients when it comes to avoiding misdiagnosis. The only actions a patient can take are to request the doctor to try to think better, and to leave the practice of a physician who appears not to like you.

On the same note, “You, the Smart Patient,” by Drs. Michael Roizen and Mehmet Oz, presents terrifying statistics of hospital problems, but their main advice is: wash your hands, make others do the same, and alcohol swab everybody's stethoscope and also the TV remote.

We can do a whole lot better than that.

First and foremost, patients should routinely obtain and review their own medical records -- or have someone do it for them. It's taken me 30 years of medical practice, and a personal tragedy, to realize and to urge this.

Amid all the complexity and change of today's health care system, one thread of continuity ties all the pieces together. No matter how many doctors and nurses and specialists and insurance companies may be involved, the patient's medical record tells the entire unvarnished story.

That record is your key to a safer medical experience. It reveals how your doctors think about you and what ails you. It fully sets forth the assumptions and the logic behind a diagnosis. Readers with no medical training, computer skills or technical vocabulary can spot errors in assumptions and logic. Once you have learned to spot the red flags that suggest problems, you can prevent them leading to disaster.

Here are some typical errors that generate red flags:

Taking an inaccurate patient history, or discounting the patient's version because of stereotyping or other preconceptions.

Failing to review the existing medical record before making a diagnosis.

Failing to address life-and-death questions adequately. For instance: raising the possibility of malignancy, and then just dropping the subject without follow-up.

Disregarding omissions, ambiguity or vagueness in an X-ray, biopsy or other data report.

Medical students and doctors-in-training making decisions for which they are not qualified.

Failing to adequately supervise students and doctors-in-training.

Practicing outside one's area of expertise (for instance, an adult specialist treating a 3-year-old).

Since April 2003, federal law gives every American citizen the right to obtain and review a complete copy of his or her own medical records, those of one's children under the age of 18, and adults who sign a consent form. Exceptions to this law are very rare.

Second, every hospitalized patient should have a “sentinel” at the bedside 24/7.

Hospitals are inherently dangerous, and becoming more so. We are in the midst of a severe nursing shortage, which is bound to worsen, due to increased hospital needs as the population ages. Nurses traditionally have protected patients from the dangers of hospitalization, but in an understaffed ward, even this highest priority may not be possible.

The patient's sentinel may need to step into the breach in care created by the nursing shortage. While the sentinel needs no formal medical training, he or she must be alert to possible dangers and prepared to act intelligently. Here's why:

You can't count on nursing staff to be on the spot in an emergency -- for instance, to suction a vomiting patient who is unable to clear his own airway. Many wards, even intensive care units, are simply too understaffed. The sentinel must be willing and prepared to act competently or summon help urgently, and to perform tasks far beyond ordinary comfort care (though the sentinel may need to take over comfort care as well).

Monitors sound an alarm only when a dangerous threshold (heart and breathing rate, blood pressure, level of oxygen in the blood) has been crossed. A sentinel can often anticipate trouble before a crisis occurs, by assessing changes in how the patient feels, behaves and looks. And by watching for ominous monitor trends before an alarm is triggered.

Transporting a patient within the hospital is potentially dangerous (what if the oxygen runs out or the IV becomes disconnected?) and so are some of the destinations (MRI suites especially). Sentinels need to be there, be alert, and know how to handle the basics.

There is always the hope that when doctors realize that patients are reviewing their own medical records with this degree of scrutiny, they really will try to “think better,” as Groopman suggests. There is also the hope that a surge of sentinels rescuing patients in understaffed wards will inspire urgent attention to the nursing shortage.

Physicians and hospitals should welcome this invaluable assistance of patients and their willing, prepared sentinels. As the theme song of “Scrubs” points out, “I can't do this all on my own. I'm no Superman.” It's time we took this plea for help seriously.

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Nathanson, a retired San Diego pediatrician, is author of “What You Don't Know Can Kill You: A Physician's Radical Guide to Conquering the Obstacles to Excellent Medical Care” (HarperCollins, May 2007).

 

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