Shaping “Self-Centered” Patients

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  • Kotecha, Mona, MD
| Jan 28, 2013

I’m lucky to practice in a national regional anesthesiology center, a hospital with five dedicated nerve block suites, each with the latest in ultrasound equipment, nurses trained in conscious sedation, regional anesthesiology colleagues and infrastructure to support regional practitioners. It seems like there is so much we can do for patients, but really, there is only so much a physician can do. We need a little help from the patient too. 

When “James,” a 400+ pound patient with multiple co-morbidities scheduled for a 2.5 hour hand procedure came in for day surgery, I knew if any patient could benefit from a surgical regional anesthetic it would be he. Not only did he have a difficult airway by all clinical indicators, but hunting through scanned medical record archives also revealed that many years prior he had a general anesthetic induction that nearly led to his death. Despite what seemed like appropriate backup equipment, his airway was nearly lost upon induction.

I introduced myself to James and asked the open ended question, “Tell me about your anesthetics in the past; any issues there?” “No, ma’am,” he answered politely. “I went to sleep for my ankle surgery, and I didn’t have any problems.”

It seemed reasonable to avoid an awake fiberoptic intubation if the case could be done with a regional anesthetic. We placed a brachial plexus block under ultrasound guidance. He received a low-dose infusion of dexmedetomine for intraoperative sedation and went home the same day. In the meantime, I gave him and his wife a letter about his past airway event and added an electronic alert to his chart.

Two months later, James returned for the identical surgery scheduled for the contralateral hand. Somewhat leadingly, I asked him, “Tell me about your anesthetics in the past; any issues there?” He smiled and said, “No.” “How did things go with your hand surgery?” I pressed further, hoping he would reveal his remote airway complication and that he had a regional anesthetic last time. “Fine. I was under for all of it.” Needless to say, he received another letter, and I asked him again to obtain a medic-alert bracelet.

I can think of innumerable patients who, in the nick of time, deliver a deadpan statement that changes the course of their anesthetic. “I got an antibiotic during surgery a few years ago and almost died from an allergic reaction,” one has said. “Which one?” I’ll ask, predictably. “I’m not sure. Don’t you have those records?”

Such fuzzy indicators of danger on histories and physicals leave us digging for more information. I recently cared for an anxious 40-year-old gentleman scheduled for an upper endoscopy who gave me a confusing history of exercise induced chest pain, syncope, palpitations, dyspnea, and, oh, by the way, “a leaky heart valve that I see a cardiologist for.” The chart notes and my physical exam revealed little. So to the dismay of the endoscopist, I promptly ignored the voice in my head that said “it will probably be ok, it’s just an endoscopy with propofol.” I shuffled cases around, called his cardiologist, painstakingly located the appropriate HIPAA form to request records and had reports faxed over that revealed, pristine coronaries, a normal conduction system and healthy heart valves. I gave the patient the reports with reassurance, and—as I do with so many patients—I asked him to place them in a binder labeled “medical stuff” and bring them to his next health care visit.

Giant, three-ring binders, folders, or in this day and age, tablets or thumb drives, full of “medical stuff,” carried around by patients. It’s my own take on what could be the greatest cost-saver and safety-promoter in all of health care. This practical recommendation is all part of my fantasy world where patients are asked to play an active role in their own health care and safety. Imagine perusing old anesthesia records, histories and physicals, and updated medication and allergy lists from a variety of providers who invariably possess fully incompatible EMR’s and maybe did not have the time to battle the HIPAA hurdles to collect all the medical information in one place.                

We’ve entered into the era of patient-centered care—an era that champions patient safety, provider communication, avoidance of “medical mistakes.” But this era is also decidedly anti-physician and assumes that we as providers are somehow purposefully unsafe. Look no further than Obamacare’s soon to be established registry of medical mistakes, which asks patients the loaded question: Did a medical mistake happen because a doctor, nurse or other health care provider did not communicate well with the patient or the patient’s family? In that registry, patients self-report perceived medical errors and decide upon their own what constitutes an error. In fact, in that registry, a doctor at another hospital who might have encountered James’ difficult airway during elective surgery made a mistake. And so did I by ineffectively communicating to him the importance of disclosing his prior airway complications.

So it’s time for patients to join us in the quest for patient-centered care, by being a bit more “self-centered” about their health care. Carrying a folder, binder, tablet or thumb drive in which they keep track of at least basic medical records is a start; patients deserve easy access to them, at minimum. After all, there’s more to delivering cost-effective, mistake-free, patient-centered care than EMRs, thought police, clipboard tyrants, efficiency experts, coding czars, regulatory sergeants and patient satisfaction surveys. There’s a patient at the center of that care, one who could probably stand to be a little more self-centered.

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