Advocate or adversary? Perils baked into the relationship between physicians and patients

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Arthur E. Palamara

Patients with complex illnesses may not be eligible for hospital admission unless their diagnoses meet InterQual Criteria or Milliman Care Guidelines—hurdles patients must first pass through in order to be admitted. Forget how bad the patient feels; an admission may be denied until the individual reaches the point where third parties agree that one is needed or unavoidable lest they be sued. At that stage, patient recovery may be beyond retrieval. What, then, is a physician’s responsibility when admission is denied?

Consider the following example as a means of answering this question.

While walking down the street, an elderly gentleman felt a sudden, severe pain in his left knee. He could go no further. Supported by his wife, he stumbled home, which fortunately was not far. For the next month, he languished in a lounge chair with his legs dependent on others. His wife did all she could to assist him, barely meeting his minimal needs. Small in stature but indomitable in constitution, she supported her husband. Physically assisting him was a chore. She developed strength she didn’t know she had.

Early in his illness, he was evaluated by a “mid- level” at his primary care provider (PCP) office who directed him to an orthopedist where a left knee meniscus tear diagnosis was made. A magnetic resonance imaging (MRI) scan was ordered but never done.

No better, the patient deteriorated in his lounge chair, becoming progressively weaker. He was not seen again in his PCP’s office. His wife’s ability to care for him during that month defies comprehension. As expected, the authorization process consumed some time and a month later he was permitted to go for an MRI.

The MRI tech was a pleasant but small young lady who lacked the physical strength required to assist the heavyset patient onto the MRI table. So the test was cancelled.

Although annoying, the cancellation proved to be a hidden benefit since it provoked the wife to call me and ask what she should do next. I sensed the desperation in her voice. As much as she loved her husband, she had reached the end of her physical and mental ability to provide care at home. I instructed her to take him to the emergency room in an adjoining building.

Prone

I found my friend’s husband lying on a stretcher, in the hall, against a wall. The emergency room (ER) was crowded. He was no longer the strong but gentle individual I had known, but now a bit confused and obviously ill. Whatever his problem, his illness was much more complex than a torn meniscus. Both swollen legs resembled mushy cantaloupes. The left knee was tender but not deformed. It could be flexed with moderate pain. There was no ecchymosis. He could—albeit weakly—lift his legs. I could find no evidence of focal neurological loss or radicular signs: He appeared to have generalized weakness, as one would find in a patient with protracted illness. An ultrasound of the painful leg revealed calf-vein thrombosis. He was placed on an anticoagulant.

The ER physician was sympathetic and recommended admission, if only for the deep vein thrombosis. It was obvious to him that, at the very least, he needed evaluation. It was abundantly obvious that a work-up was not going to occur as an outpatient. Her husband being so weak, it was amazing that the wife was able to care for him so long.

The type of admission was left undetermined. Most patients don’t know that categories of admission are more complex than quantum physics and infinitely more mystifying.

While mathematics may be a pure science, hospital admissions are not. Admission policies have more variations than rabbis interpreting the Torah. There is no unimpeachable source. But there is an overriding principle: Keep an insured patient out of the hospital and use every contrivance available. While hospitals love to admit insured patients, it is only after criteria for admission are met and hospitals are guaranteed payment. Regretfully, patients are the casualties of the war between insurance companies and hospitals.

The health maintenance organization (HMO)-contracted hospitalist could not promptly diagnose the patient. Neither of us had an explanation for the bilateral leg edema, weakness, new-onset mental confusion—let alone the inability to walk. Within the first 24 hours, he received a computerized tomography (CT) scan with contrast of his abdomen and pelvis.

Except for a few non-obstructing renal calculi, no major problem was found. Nor did it explain his lower-extremity edema. Routine lab work found little amiss. Hepatic enzymes and hemoglobin were near-normal. He had mild renal failure.

The hospitalist suspected a lumbar radiculopathy, although the neurological exam revealed no major deficits. The MRI of the back failed to find spinal stenosis. There was an annular fissure. A “side-walk” consult with a neurosurgeon opined— without looking at the MRI—that the tear could be responsible for the patient’s left leg pain. Physiotherapy was recommended. But since the patient was still labeled under “observation,” he was not eligible for physiotherapy.

Discharge

The hospitalist decided to discharge the patient to a nursing home where he could receive physiotherapy, such as it is. My experience with rehabilitation facilities is not edifying. They are more accurately called nursing homes where elderly people are warehoused, bedded in foul-smelling rooms and entertained by a ceaseless barrage of CNN or Fox News blaring from incessant televisions. Physiotherapy at these institutions is often a euphemism. Patients are wheeled into the rehab room, asked to stand, perhaps take a few steps and then sat down. See you tomorrow! Then it’s off back to bed where they vegetate until the next session.

My friend, who had only slightly improved, was to be relegated to this level of care. With elevation, the lower-extremity edema had improved but had not completely resolved. His attempts to stand and ambulate were not successful. Deprived of these functions for over a month, they were not to be easily regained.

To say that I objected to his premature discharge would be an understatement. Whatever caused his debilitation had not yet been diagnosed and certainly not treated. Nor was there any expectation that his condition, largely ignored for a month, would be rapidly cared for as an outpatient. Nor do nursing homes show much proclivity for investigating and treating underlying maladies.

What patients come in with they go out with—or not. This is not a very compassionate way to treat our elderly, but perhaps there is no redemption from our human frailty.

Meanwhile, the patient remained in his bed but became more interactive; his swollen legs and mental acuity improved. The cause of his left leg pain remained undiagnosed. He could not stand, partially as a result of disuse.

Then three days into the admission, the hospitalist ordered an MRI of his left knee and finally hit pay-dirt: The patient had a non-displaced tibial plateau fracture. Perhaps if his fracture had been diagnosed earlier, he could have avoided a month of decline and the cost of hospitalization.

Points of contention

There are several issues worthy of discussion. One is our desire to constrain costs has imposed a barrier to ordering expensive tests like MRIs. If dedicated to patient care, physicians are challenged to overcome the insurance hurdles, fight with scheduling secretaries, obtain authorizations from medical directors, meet all the imposed requirements, review test results and figure out how to treat the patient. This process usually takes a month. If the patient requires admission, similar barriers are erected. Hospitals and insurance companies hope

that the patients will get better and not need the test or admission. Or, indeed, experience a more final solution. Some patients will not get better, as in the case of this patient, who languished at home waiting for the “system” to give him the care that he needed.

Each of his diagnoses—tibial fracture, deep vein thrombosis, immobility, lower-extremity edema, hospital-acquired bilateral erysipelas and a right ankle ulcer—do not qualify for in-patient admission. Since he was admitted for observation, the HMO was not responsible for his hospitalization. Even worse, without an in-patient admission, his HMO would not pay for his nursing home.

Although none of the individual diagnoses were worthy of admission, one would expect the aggregate of all the diagnoses would justify admission according to InterQual and Milliman criteria? Such a determination would have eased the burden of admission and the cost—now assumed by the patient—which seems patently unfair.

The second issue: To whom does the physician owe a greater obligation—the patient or the insurance company? If he wants to keep his job, he’d better support their policies. In reality, hospitals maximize their reimbursements at the same time as insurance companies try to reduce theirs. It’s an ongoing contest.

Lost in this shuffle is the physician-patient relationship. Since the hospitalist has only a transient relationship with the patient, they often fail to appreciate the patient as a person and consider them an unresolved clinical problem. Tradition and the American Medical Association (AMA) Code of Ethics obligate the doctor to advocate on behalf of the patient, but economic pressures place the physician in conflict with his employer and, indeed, the hospital. Physicians’ failure to advocate on behalf of their patients is a blow to the foundation of the medical profession.

European countries offer much more robust care and do not seem to suffer this conflict. Their costs are half of ours and they have better outcomes (by many criteria).

Our fragmented, expensive public-private, confused system appears to be the most important issue facing voters in the 2020 election. Most beneficiaries are unhappy with their current coverage (or lack thereof ) for a variety of reasons. They have lost faith in their insurance companies but retain confidence in their physician. We as doctors don’t want to abuse that trust.

Arthur E. Palamara, MD, is a vascular surgeon in Hollywood, Florida, and is associated with Memorial Regional Hospital, part of Memorial Healthcare System in the same city.

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