Healthcare Stinks: The Revenge of the Shrimp

shrimpSo I have this condition called gout.  It’s manageable, as anyone can tell you, if you behave within very reasonable dietary guidelines.  These very reasonable dietary guidelines include avoiding things like organ meat like liver and brains, which is pretty easy, broccoli (seriously?) and beer (forget it).

There’s also an unwritten, but very real, rule of living with gout which goes something like “don’t poke the beast”.  In other words, because gout multiplies any inflammatory issue you might have, don’t do anything like “getting out of bed” that might inflame the joints.

So I start this new job, and as part of the initiation we go off to do a week in the woods team building.  Really not my thing, and I’m paying very close attention to “not poking the beast”.  By dinner time on the last night I’m feeling pretty good.  I haven’t gotten fired yet, my team (GO PLOWS!) isn’t in last place, and the beast snores contentedly.  And that’s where it all goes to shit.

They feed us a huge dinner at the restaurant on the top of the mountain where the views look like this:

PANO_20170510_175311

Yes.  That really is the view.  We stomped all over the mountain all day and I’m beat and hungry.  There’s a fabulous shrimp thing on offer.  Garlic and oil.  I can’t get enough, and go back for thirds.

In case you haven’t guessed by now, those very reasonable dietary guidelines include “don’t eat shrimp”.  Within 24 hours my left big toe is bright red, swollen and ON FIRE.  With every heartbeat the toe throbs as if I was hitting it with a hammer.  And of course it’s my own damned fault.

Oh well, accidents happen.  I knew the shellfish restriction but because I seldom run into a situation where shellfish is the best thing on offer I totally forgot about it.  Like I said, it happens.

The usual treatment for this is to hit it with a decent dose of prednisone (steroid), slap ice on it, keep it off the ground for a week or so and once again, you’re good to go.  Sadly, rest is not an option.  In fact, this job seems, in a relentlessly upbeat way, to be determined to kill me before I even figure out where the mens room is.

First, there’s the walking tour of the campus, sprawled scenically over a quarter of a mile of low-rise brick buildings.  My cube is, of course, as far from the garage as you can get without being off-campus.  And being a big company, the first few weeks is an endless march from one meeting room to another.  While this is a laid-back place, full of dogs and such, I just can’t imagine that putting my foot up on the conference table with an ice bag on it will be well-received.  So I sneak in ice-breaks between meetings and continue to poke the beast.

And after one day in the office, we have to fly to Austin for a week of walking around.  Like I said, they’re trying to kill me.

So of course the toe doesn’t get better as fast as it usually does.  In fact, after a couple of weeks, when we’re winding down the prednisone, the toe’s only a little better but because I’m continuing to poke the beast by walking like a duck all day both knees and the other big toe are starting to get involved.  It’s clear that the usual script isn’t going to work here.

<Skip long sad story about communication and scheduling misfires within the office of my regular rheumatologist>

<Skip shorter, equally sad story about communication and scheduling misfires between my regular rheumatologist and the covering rheumatologist>

<Skip even shorter, equally sad story about communication and scheduling misfires within the office of the covering rheumatologist>

So we’re a month out from the start of this attack and it’s not fixed because I didn’t rest it enough, and I’m finally in to see a rheumatologist.  She takes a history, takes a look at the right toe where the attack has now moved and proposes a two-prong strategy: lots more prednisone (which I agree with) and potentially some colchicine but only if a blood test shows good liver/kidney function.  Cool.

It’s noon time on a Friday.  As she puts in the lab order I ask innocently,

ME: Is that gonna get done in time to write the colchicine scrip today?

HER: Oh sure, I’ll write STAT on it and we’ll have the results by the end of the day today.

Somehow, I am not reassured.  But I limp gamely across the hallway to the lab, literally 20 feet away.  The order is right there and they’re waiting for me.  What service!  The guy looks at my order and has only one question for me:

HIM: Are you getting imaging done?

ME: Huh? No.

But my spidey-senses are tingling.  This can’t simply be an idle inquiry from a nosey phlebotomist.

ME: But it says STAT there right?  That means it’s going to be done right away, right?

HIM: Oh yeah, it says STAT right here.

As I leave the lab my spidey-sense has not calmed down one bit, so I ask one more time:

ME: STAT, right?

HIM: Right

Suffice to say, one should always, always, always trust ones spidey-sense.  STAT written in that field, on that form, does not mean shit because the tests weren’t run by end of day, no results for my rheumatologist and thus no colchicine for me.  The fact that I wasn’t “going for imaging” put my sample in the “whenever” bin, STAT be damned.

So to put this in perspective, the strategy to kill off this gout attack that my rheumatologist cooked up wasn’t executed because two offices on the same Epic installation and located physically within 20 feet of each other couldn’t communicate the fact that this test needed to be run TODAY rather than next business day (i.e. three calendar days).

Even if the colchicine scrip is written on Monday, because of the way the prednisone scrip is written, it’ll be paired with 30mg of prednisone, rather than the 50mg it would have been paired with on Friday.  A tragedy? No.  Less effective?  Probably.  Completely unacceptable?  You bet.

What does all this say about anything?  Even in situations where providers and staff are on the same system, nay even within the same physical office, working as a team the most expensive health care in the world delivers a quality of service that would be unacceptable from a dry-cleaner or an auto mechanic.  I work with teams for a living, and if two of them dropped the ball like this, there would be consequences.  By contrast, I suspect that by the metrics Atrius Health collects, this episode will count as a huge success.

This slipup with the lab and rheumatology was only the last in a series of unpleasant interactions with the system (see skipped episodes above) that all illustrate the same point – providers within the same office, or across offices in the same EMR, are unable or unwilling to communicate such that what’s best for the patient actually happens.  Which proves, as much as anything can, that’s what’s best for Harvard Vanguard/Atrius Health and what’s best for the patient are not the same thing.

Full disclosure: All this sadness takes place within Harvard Vanguard/Atrius Health and Epic.  I now work for AthenaHealth.  That said, I can’t say this wouldn’t happen at an AthenaNet provider.