When I was called to the Emergency Room to admit a patient from a nursing home, I was surprised to learn that the patient was only in her 30s.
Reading a bit more about her, I learned that she had paraplegia, and her care needs had extended beyond what her family could provide for her at home. Digging even further into her chart, I discovered that the patient’s paraplegia was not due to some sort of trauma, but rather to sheer bad luck in a case of idiopathic spinal stenosis (a narrowing of the spine).
As I walked downstairs with my intern to meet our patient, I discussed the need for us to carefully examine her sacral decubitus ulcers (pressure sores where the spine meets the buttocks), as these could be the source of the uncontrolled infection that was tipping her into septic shock.
To call the gaping wounds in this patient’s body “ulcers” would be the grossest understatement in the history of my medical career. As we unpacked her multiple wounds and realized that there were craters of flesh missing from this poor woman’s body, I was brought to tears by the simple fact that this degree of devastation could happen to a person who was regularly seen by health care providers both inside and outside of the hospital.
Residency recruitment season has been in full swing over the past few months. Swarms of eager fourth-year medical students clad in black suits can be seen strolling hospital corridors during their interview day tours.
My own pursuit of medicine as a career stemmed from no truth greater than a desire to help others. As a medical student, I spend limited time rotating across different services, so I rarely get very in-depth looks at hospital processes, field-to-field struggles, and other subtle nuances of a career in medicine. These nuances include, of course, the extent of the failures of the health care system.
But as I progress further along in my medical training, this illusion of “helping others” through health care often unravels as I see the many different ways in which the system lets down both patients and providers.
One of the earliest lessons I was taught as an intern was that “people are allowed to make poor choices.” The acceptance of this critical fact became ever more important as I watched patients die from drug overdoses, suffer from COPD exacerbations while continuing to smoke, retain overwhelming amounts of fluid due to heart failure exacerbations at the hands of dietary indiscretions, and go into near diabetic comas because of neglect to properly take insulin.
By the time I came to terms with being unable to help many patients help themselves, I realized that the very foundation upon which I had laid my medical career had been shaken. If I could not help my patients beyond simply stabilizing them until their next medical crisis, then what exactly was I doing here? How is this never-ending cycle (triage, admit, stabilize, discharge, readmit) so easily accepted by our current health care system?
Frequent readmissions for congestive heart failure and COPD exacerbations often occur because really, old habits die hard. These situations don’t bother me as much as the disease processes which run rampantly uncontrolled because of a simple lack of therapy.
Take for example diabetes and HIV, two vastly different clinical conditions that can usually be managed very well with the right medication regimens. Why then, in today’s world of modern medicine with advanced antiretroviral therapies for HIV and a growing panel of medications for diabetes, have I seen patients dying of AIDS and diabetic crises?
During one call in the medical ICU, I encountered an all-too-familiar patient scenario: a young man with rampantly uncontrolled diabetes and its many subsequent complications, including end stage renal disease requiring dialysis. As I pondered how this patient ended up with devastating long-term complications from an easily treatable condition, the nurse called me to the patient’s bedside for a private conversation: “Doctor, I think I know what’s been stopping up my bowels. I’ve been eating detergent.”
He told me that he had been eating roughly one teaspoon of powdered cleaning detergent about five times per day since 2011. If you do the math, that’s about 7,300 teaspoons over a four year period, or roughly 76 pounds of detergent. Despite multiple readmissions for diabetic ketoacidosis due to non-adherence with his insulin regimen, nobody was ever able to ascertain that he was consuming pounds upon pounds of a toxic substance.
There’s no doubt in my mind that this behavior contributed in part to the severity of his overall clinical condition, and also shed light on some of the reasons why the patient had been so non-adherent with his medical regimen.
But there was no medical documentation of this patient’s longstanding history of pica (the desire to eat substances like clay, dirt, cleaning products, and sand) or any other associated mental health conditions. This would suggest that despite this patient’s many readmissions, medical providers never really ascertained this critical aspect of his daily life. And, ultimately, this means that while we likely counseled him repeatedly about the importance of adherence to medical therapy, we never really managed to get to the bottom of what was causing his non-adherence.
A similar situation happened as I watched a woman in her 20s die from end-stage AIDS because she could not manage to swallow her anti-retrovirals. Note after note in the medical records documented this patient’s inability to take her pills. There were some notes from mental health providers, but little documented about treatment of what was considered a psychological barrier preventing her from taking her medications.
When we were called to admit her to the medical ICU, we were told that her family members were ready to have a PEG tube placed so that they could administer her anti-retrovirals. Sadly, she died from complications of AIDS during that hospitalization before she even had a chance to have a PEG tube placed.
Substance abuse, easily one of the most widespread mental health problems in this country, has yet to be adequately addressed by the current health care system. Rehab services are far and few between for patients who are addicted to drugs and alcohol.
After we manage their withdrawal or complications from drug use, we counsel our patients on the “importance of abstaining from drug use.” Would we ever counsel our patients with hypertension to abstain from stress, or our patients with diabetes to abstain from sugar, without also providing ongoing medical care for their clinical condition? Most certainly not.
In a time when mental health funding has been cut across the board, medical providers who are already overworked are often unable to address the interplay between mental health and chronic disease, despite realizing just how detrimental untreated mental health disorders can be for the physical and mental health of our patients. This concept is not a new idea; in fact, a 2000 study from JAMA demonstrated that depressed patients are three times more likely to be noncompliant with medical treatment plans when compared to non-depressed patients. Despite this knowledge, the current healthcare system sidesteps the importance of integrated management of mental health alongside chronic medical disease.
For my patient with gaping decubitus wounds, the medical records discuss at length her unwillingness to quit smoking, which hinders wound healing. And while I will never really know what caused this patient’s bedsores to turn into such severe wounds, I will also never be able to shake the feeling that this should not have happened to her. Surely there must have been some way to prevent these catastrophic injuries, which will likely lead to her death.
Similarly, I will never be able to escape the images of the patients I have lost at the hands of AIDS, diabetes, and drug overdoses. I will never escape the feeling of helplessness that washes over me every time I watch my patients suffer from end-stage complications of diseases that would be almost entirely avoidable with adherence to modern medical therapies.
On a day-to-day basis, perhaps I do help some people. But overall, encumbered by the limitations of the existing health care infrastructure and trapped beneath the weight of circumstances that extend beyond the realm of my control, I rarely ever feel as though I have made a difference in the lives of my patients. And this truth is the biggest disappointment of all.