How Did We Get Here?

I am trying to understand what happened to medicine, to health care, and to common sense. While the pandemic may have emphasized the pervasive problems in the health care system, the problems started a long time ago.

I am going to use a recent patient as an example. For months my staff and I had been caring for an elderly woman whose mental status and general health had been in decline. She’d had minor skin breakdown for several months, and we had done all the appropriate things, but it was obvious that her nutritional status was going downhill. I provided nutritional supplements, but her primary care doctor told her not to take them when they gave her diarrhea. I tried to get her to see a gastroenterologist. I recommended hospital admission and a feeding tube. She refused and promised she’d eat. Despite the devoted efforts of her husband, the day came when she presented to the wound clinic with a horrific sacral pressure injury that had evolved rapidly over only a few days.

The patient required immediate hospitalization. I wrote a detailed admitting note in which I explained that I’d watched the patient deteriorate over several months, losing more than 40 lbs. Her albumin was less than 2.8 gm/dL, her vitamin D level was in the teens, and her daily calorie count was less than 800. The pressure injury was a symptom of malnutrition that I’d been unable to impact and she needed a feeding tube. I talked to the doctor in the emergency department. I made extra copies of my notes and gave them to the patient’s husband so he could hand them to the admitting physician because I knew from experience that the notes I provided to the ED would not be included in her admission records.

The day after admission, a registered dietician evaluated her, diagnosed her with malnutrition, and made recommendations for her dietary intake, but she ate almost nothing over the ensuing days. Three days later, the plan was to discharge her to a rehabilitation hospital. At that point, I called the hospital chief of staff. I explained that it was unethical to send a starving woman to a rehab hospital. Either we should put in a feeding tube, or she should be placed on hospice.

I talked at length to the patient’s husband, and miraculously, the patient had a day of lucidity in which she expressed clearly that she was ready to meet her Maker, that she did not want a feeding tube, and that she was quite content to be placed on hospice. With the support of their church family, she was discharged to a personal care home that specializes in hospice, and eight days later, she died peacefully.

I would call that a happy ending. She and her family made an informed choice that was right for her. What frightens me is that we nearly discharged an actively dying woman to a rehabilitation hospital, and the only reason we didn’t is that I went bananas.

Malnutrition is not a difficult diagnosis. She had a huge pressure injury and her husband had told the hospitalist she was not eating. The woman obviously looked like she was starving, a fact easily confirmed by objective laboratory data that a medical student could interpret.

What has happened to health care in general, and to physician training in particular, that we can’t make a simple diagnosis? I see hospitalized patients whose feet are hypoxic, primarily because their hemoglobin is 7. When did we stop teaching basic physiology?

When did physicians stop caring what happened to patients? I once referred a girlfriend to a surgeon, trying to encourage her by saying, “I know he will treat you like he would his wife.” She responded, “Does he like his wife?” It’s a fair question because the stories that patients tell me about their encounters with the medical system make me ashamed to be a physician.

For all our advances in technology, we are not providing better medical care. Generally, I’d say we are providing worse care, particularly to hospitalized patients. There are reasons such as fragmentation of care, fear of litigation, and the pressure to discharge patients quickly due to financial concerns.

However, at the core of these problems are a lack of scientific curiosity, a lack of fundamental clinical knowledge, and the failure to treat every patient like they were members of our family (assuming we like our family). I know this is a tirade, but I bet it resonates with a lot of people.

I don’t know how to turn the tide of worsening medical care, but patients with chronic wounds are the ones most affected by it and it’s time we at least talked about how we got here.

Caroline E. Fife is Chief Medical Officer at Intellicure Inc., The Woodlands, TX; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands; and co-chair of the Alliance of Wound Care Stakeholders.

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