— Fixing the small things can make a big difference
by Fred Pelzman, MD, Contributing Writer, MedPage Today
December 6, 2023
Fred Pelzman is an associate professor of medicine at Weill
Cornell, and has been a practicing internist for nearly 30 years. He is medical
director of Weill Cornell Internal Medicine Associates.
Today we missed another opportunity.
Actually, several opportunities — several opportunities to
provide care to multiple different patients.
The No-Show — For a Good Reason
This morning, at the beginning of our practice session,
there was a patient scheduled for a new patient visit with one of the residents
on their ambulatory block rotation. It was a 1-hour appointment that, according
to the scheduling system, had been made approximately 10 days ago.
Unfortunately, the patient was a no-show for their appointment
because it turns out they are currently an inpatient in the hospital — our
hospital, same institution, right across the street, using the same electronic
health record.
Looking back in the system, we can see that the appointment
was made on the day that the patient, brand new to our hospital system, arrived
in the emergency department with a series of systemic and constitutional
symptoms. It appears that after several hours under their care there, one of
the care navigators called the scheduling team at our practice and requested a
new patient appointment for “follow-up from the emergency
department.” However, just after this event occurred, it seems that new
results came back which necessitated the patient being admitted to the
hospital, where they have remained ever since, getting evaluated and treated.
No one bothered to cancel that appointment, and no one on
the inpatient team taking care of them noticed that they were simultaneously
scheduled for an outpatient initial visit appointment today in our practice,
right across the street. No one bothered to follow up, no one bothered to call,
probably because it didn’t come to anybody’s attention, or no one thought it
was worth the effort.
The Question That Should Have Been Asked
But let’s go back to the very beginning, when the patient
was being evaluated in the emergency department. At no point does it appear
that anyone asked this patient, an elderly woman with a number of complex
medical problems who was on a lot of outpatient medicines, whether she had a
primary care provider in the community who had been taking care of her.
It literally took me 30 seconds to look into the electronic
health record, under the system that connects similar users of the same EHR, to
find that she has a primary care provider right in her neighborhood who manages
most of her medical conditions and sees her regularly, most recently 2 months
ago. So, in actuality, no one should have been making her a new patient
appointment here, with a brand-new set of doctors, more than 5 miles from where
she lives, unless she somehow told somebody that she was firing her current
doctor and wanted to continue all her care here after a brief emergency room
visit.
I remember oh so many years ago, when I was an intern doing
admissions in the hospital, the first question we asked patients was,
“What brings you here today?” But the second question we were taught
to ask was, “Do you have a primary care doctor?” And who is it? Do
you know their phone number?
Without fail, the next morning on rounds, the attending
would want to know who the patient’s primary care doctor was, and whether we
had reached out to them to find any information that might be critically useful
in the management of their current clinical reason for admission. What was
their last EKG like? Do we know what their creatinine has been most recently?
Are they compliant with their medications, according to their primary care
provider? What’s their baseline mental status; who is their healthcare proxy;
and do they have support at home?
Woe to the intern that came to morning rounds without all
this information, or without at least having made the effort to reach out to
the primary care physician in the community.
Several Missed Opportunities
In scheduling a patient for an appointment, they probably
aren’t going to attend, the folks who made it missed an opportunity for care —
multiple opportunities, in fact. The patient in question should have had a
follow-up appointment arranged with their primary care doctor, to make sure
they got the appropriate care and follow-up from the emergency department
interventions and treatments. And multiple patients were denied opportunities
to get care from us, because that 1-hour appointment was scheduled for a
patient who was definitely not going to show up for it. And the resident who
was scheduled to see that patient sat around not learning, not taking care of a
patient — definitely a missed opportunity.
No system is ever going to be perfect, but I think as we try
and build a better healthcare system in this, the late early 21st century,
you’d think we’d be able to design systems that would prevent bad appointments
from being made, lower no-show rates, prevent late arrivals, and avoid the
wrong care at the wrong time with the wrong provider.
We desperately want our patients to have access to
healthcare and to come in and see us, and we want to engage them in their
health and make sure we do everything we can to get them as healthy as they can
be. But if we make appointments all wrong, if we can’t confirm they are coming,
if we can’t get them transportation, if we can’t offer them telehealth visits,
if we can’t get them onto the schedule because things are cluttered up with
sometimes meaningless visits, then we’re doing a disservice to everyone.
Just the other day I saw a patient who told me he’d seen a
specialist a couple of weeks earlier, who told him they were going to be
arranging for him to undergo a particular test. But since then, he said, he
hadn’t heard from anybody. He was enrolled in the patient portal, but he was
not really sure how to use it. He reassured me that his contact information was
all correct, his cell phone was the preferred number and was working, and that
he had received no messages from their practice.
A quick outreach to the practice showed that they had been
trying to reach him but had been unable to, and with some gentle nudging we
were able to make sure everything was connected and set up. But this stuff
should happen by default. Loose ends should get tied or shouldn’t exist in the
first place.
Although there are so many things that need to be addressed
in the healthcare system, including major issues such as institutional bias,
lack of adequate insurance, low health literacy, and inequitable care, there
also are still so many broken small parts of the huge machinery of healthcare,
and fixing those could make a big difference in how things go.
For all of our patients, and for all of us.
