Last week I had a front-row seat to watch American Healthcare flushes tens of thousands of dollars down the drain in a span of a just few hours.
You’ve heard that America has high healthcare costs and relatively poor outcomes. But in addition to the waste called out in that article, I see a different kind of waste and I see it every single shift in the ER. The problem is obvious: we rush through the important act of providing care, and rushed work yields in poor results. To quote Ben Franklin, “Take time for all things: great haste makes great waste.”
Isn’t our country’s health worth taking time for?
Think back to the olden days of doctoring. Imagine a wise old doctor who knew your name and your history, medications, and living situation. He might visit you at home and he would take time to explain, educate, and then prescribe a plan that worked for you. (You, meaning the unique individual, not a composite endpoint in a research paper.)
Now fast forward back to today. In 2019 your provider fits your visit into 15 minutes. Those 15 minutes include reviewing your electronic chart, your medication list, and allows time to answer a question about just one of the medical problems you were concerned about. There isn’t time to discuss the side effects of the cholesterol medicine the guidelines tell you to take or to talk about how with your new insurance your asthma medicine is now $320. Maybe you can talk about those at your next visit in 6 months, and you hope you don’t get sick before then. If you’re young and healthy, you’ll probably be Ok. But what if you are one of the older or less fortunate patients I saw on my recent shift?
It was not an unusual day in the ER. The first patient I saw has congestive heart failure and also COPD. She lives alone and after her recent admission for COPD, she had been started on a steroid. She was “pushed out of the hospital after 2 days” (her words) despite questioning what the steroids would do to her CHF fluid balance. 4 days later she was back in the ER, swollen up like a waterlogged peach, a result of the steroid causing fluid retention. An ER visit and 3 more days in the hospital will likely cost $17,000 or more.
Patient #2 was on blood thinners and had lost her balance and fallen. She had gone to her Primary Provider because of a cut on her ear, but that Provider sent her to the ER for “evaluation and CatScan” because, correctly, folks that are on blood thinners who fall and hit their head can have bleeding in their brain. The Primary had followed appropriate practice patterns, but had not taken a few moments to involve the patient in decision making. This patient was 91 years old, certainly she has acquired some wisdom in all those decades? I sat and talked with her, examined her, and then asked her directly: if there is bleeding in your brain, would you want surgery on your skull and brain to try to fix it? “What for honey, I’m old! I just want someone to bandage my ear!” So bandage her ear we did. At the end of the day, the total bill for her bandage was about $2200 (Primary visit, RN costs, ED facility fee, professional fee, etc).
Patient #3 has Parkinson’s and was in the hospital last week for pneumonia, was discharged to a nursing home. His wife asked for him to be brought back to the ER because “he isn’t doing well, even though he was so good just 2 weeks ago.” Unfortunately, the expected course of Parkinson’s is a roller coaster: good weeks and bad weeks, but always averaging downhill in a terminal fashion. No one had sat down and explained this to the man’s wife, so she was expecting him to bounce back to more of the good days. I sat and talked with his son — who now understands— but the wife’s interest was in getting him admitted to the ICU so that they could “do everything.” I found myself wishing that the team that cared for him last week could have taken a few minutes to set realistic expectations for the wife. I don’t know exactly how much his healthcare expenses are, but they will be over 6 figures this year, despite a life expectancy of less than a year.
Patient 4 is addicted to heroin. His friend had survived an overdose last week, and then this week Patient 4’s had the bad luck to OD. Narcotic overdoses are tragic and all too common; Narcan is an antidote that is available by prescription, yet less than 2% of overdose patients get this prescription. Think about that for a minute: there is an easy and safe reversal agent but 98% of patients who need it are not getting it. This is a public health crisis leading to lost lives and costing our country billions. It was very busy in the ER last week, but had someone taken the time to prescribe the friend this life-saving nasal spray, things might have been different.
In each of these cases a visit to the ER could have been avoided if a Physician had just slowed down, or listened, or asked a patient what they wanted, or thought ahead. Instead, the system forced them to provide hasty care with the resultant sloppy and wasteful results. I do wonder, what would happen if we all slowed down and spent more time communicating with patients? Maybe a little time spent at the bedside today could prevent hours in the ER, or days in the hospital tomorrow?