One case, two doctors, one unfortunate outcome. What would you have done?
A discussion of geriatric admission and the perils of overtreatment.
Burning belly pain awakens Marcus at 2 AM. Having it multiple times before, he’s tired of waking up and having to walk until it goes away. ‘No more,’ he declares, ‘I’m going to the ER to get some relief.’
Marcus lives alone. Marcus insists on being very independent at age 81. He doesn’t leave for the ER until he has fed the dog, washed up, brushed his teeth and made his bed.
Marcus moves slow but is remarkably healthy given his age, except for Moh’s surgery. Hands tremble a little and he’s sometimes forgetful. As long as he keeps his routine and stays close to home he is fine.
Anxious because he doesn’t like to drive in the dark, Marcus arrives at the ED a little gruff and lets the triage nurse know, “My stomach is burning and I want something to stop it.”
The triage nurse sees an elderly gentleman, skin weathered and wrinkled, who probably shouldn’t be out alone. Having been reprimanded before and not wanting to miss the door-to-EKG time limit, she does an EKG by hospital-ordered protocol.
Now annoyed at getting an unwanted EKG, and still no belly relief, Marcus is tired of waiting. Finally, he gets brought to a room, where Dr. Williams meets him.
Williams sees an elderly-but-spry, well-spoken gentleman. He has a bag with him. Marcus never goes anywhere without his ditty bag. As Marcus removes a red flannel shirt, Williams takes a history. Burning epigastric pain early in the morning, better when upright and walking.
No change in exercise tolerance. Marcus still enjoys walking his dog each day without difficulty. No shortness of breath or chest pain, maybe some nausea and diaphoresis when it gets real bad. When asked about his diet, Marcus replies “don’t eat much during the day, but I like a big meal before bed. It makes me sleepy.”
Physical exam reveals no abnormalities. Lungs are clear. Belly is soft with hyperactive bowel sounds. When listening to Marcus’s heart, Williams thinks, “I hope my heart sounds this good in 40 years.” Good equal distal pulses. No JVD. Neurological exam is normal except for mild tremor. EKG reveals NSR, rate 78, with a borderline right bundle branch block.
Williams thinks long and hard. Marcus is old. Williams orders a GI cocktail. After drinking it Marcus feels great, symptoms relieved.
Hardly waiting to get his instructions or famotidine prescription, Marcus leaves. He doesn’t want his dog to be alone for long.
The next evening, Marcus eats his usual large meal before bedtime. He awakens with the same damn burning. He heads back to the ER.
The medicine didn’t last long. More anxious about a second night’s drive, more angry about another EKG and being asked all the same questions again, Marcus gets demanding. That’s not the way they did things in Marcus’s time.
The triage nurse sees this as inappropriate behavior. She brings Marcus to a room, sharing her concerns about chest pain and altered mental status with Dr. Brown.
Dr. Brown walks into the room to be greeted by a, ‘Where’s that other no good doc?’ Brown sees Marcus’s bag and thinks ‘suitcase sign.’ Brown doesn’t understand Marcus’s question or anger. Eying a wrinkled old man in a worn, flannel shirt, Brown runs through the list of causes for delirium in this age group.
Very annoyed by the orientation questions, Marcus answers hesitantly and slowly, albeit correctly.
It’s a bounce back with a suitcase, Brown thinks, he has to stay. Upset about Williams’s lack of workup the night prior, Brown orders CBC with diff, CMP, Lipase, Cardiac Enzymes, UA, ETOH and CXR.
“What about my belly pain?” Marcus growls. Brown orders 50 mcg sublimaze.
While waiting for the labs, Brown is informed, “That old guy is still complaining of belly pain and being demanding.” Brown orders another 50mcg sublimaze.
Labs return within normal limits except the CO2, albumin, and anion gap which are all slightly decreased. Brown is worried. There’s no explanation for the pain.
Brown reexamines Marcus who is sleeping soundly. Awakened suddenly, Marcus is startled and confused for a minute. Brown examines the belly: soft, nontender, but bowel sounds are much quieter than before. “Does it still hurt?” “Damn does,” Marcus replies. Brown orders another 50 mcg of sublimaze, CT abdomen and pelvis with IV dye.
The CT returns normal. Brown admits. Marcus is old and has belly pain.
On the floor, Marcus is more confused, giving the nurses a hard time. The nurse cannot hear any bowel sounds and belly may be slightly distended. Orders are obtained for soft restraints and an NG tube.
During NG insertion, Marcus vomits the large meal he’d had before bed. He aspirates. Several days later he dies of ARDS.
Williams’s care of Marcus is reviewed due to the bounce back. It’s deemed questionable. Brown’s care is never reviewed. It did not fall out on criteria.
How would you evaluate the care provided by Drs. Williams and Brown? Was it appropriate to admit?
50 to 60% of elderly patients with abdominal pain get admitted. 30 to 40% of those admitted with acute pain will have a surgical diagnosis. Marcus’s pain was chronic, not acute. Of those admitted, 10 to 14% will die in the hospital. The majority of those that are admitted with acute pain and surgical diagnosis will have abnormal labs or imaging. If the mortality rate is calculated on the admission rate of all elderly patients with acute or chronic pain and normal or abnormal diagnostic testing, the mortality rate is higher for those admitted than those discharged.
Why we are so quick to admit elderly patients with any abdominal pain. Does the peer review process rewards physicians for overutilization? Williams’s care was reviewed because of the ‘bounce back’. The review found Dr. Williams’s management questionable based on the lack of a workup – even though there was no indication for a work up. There was no bad outcome. No diagnosis was identified on the second visit despite an extensive work up. Brown’s work up, on the other hand, was never questioned, although it ultimately resulted in Marcus’s death. Despite evidence suggesting that overutilization endangers patients and societies’ fiscal security, doctors continue to over treat and over test due to fears of peer review and fears of complaints from patients and their families.
This conditioning starts in medical school. To avoid being humiliated on morning rounds, over order, over treat, over diagnose and over utilize. Attendings’ criticize for misses or deficient orders, rarely for excess. Fledging physicians are taught to make decisions based on their own interests: ‘What will keep me out of trouble?’ ‘What would my attending want?’ ‘What will advance my career?’
Compounding this systemic problem is the unseemly fact that over testing can pad the physician’s bottom line, resulting in bonuses, incentivized hourly pay, and job security. Medicine is unique in that doctors are ethically required to say no to their customers. In Marcus’s case, the hospital reaped financial rewards and Dr. Brown was rewarded with job security. Dr. Williams, Medicare and the tax-payers lost, and Marcus died.
Malpractice reform should encourage litigation against health care systems as opposed to individual health care workers. Peer review should be rebalanced to not only review the omissions of care but also the emissions of care. If physicians don’t self-regulate, non-physicians will regulate them.
The geriatric population is the cash cow of the health care industry. End-of-life care represents a significant chunk of the health care dollars. Geriatric patients don’t always want all that we have to offer. Marcus went to the ED for relief from his belly burning, not an elaborate diagnostic workup. It is easier and more profitable to assume patients want every test and every treatment. Physicians pressured to see more patients per hour, generate more RVUs, do not have the time to explain the risks and benefits of each test or treatment.
Medical businesses need to be held to the professional dictum, ‘Our vested interest will not supersede that of our patients.’ Marcus would have preferred to die at home with his dog rather than in respiratory distress tied to a hospital bed.
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written by Graham Walker , May 15, 2013