Although
I didn’t know Jess Jacobs, a young woman who tragically died on Monday after suffering for years from two rare diseases, I have learned much
about her from her blogs detailing
her encounters with the healthcare system.
I have learned that she suffered greatly from
her conditions, postural orthostatic tachycardia syndrome (POTS), an autonomic disorder, and from Ehlers-Danlos Syndrome (EDS),
a rare hereditary disease of connective tissue.
I learned that her suffering was unnecessarily
compounded by a health care system that, by her own detailed reports, failed
her at every point.
On
February 14, 2014, she wrote of her frustrations over
receiving the following letter from her primary care physician:
Hi Jess,
POTS is a rare diagnosis, and I am by no
means a specialist in the treatment of it. I cannot comment on whether
treatment with opioids is the best route or not. My only suggestion was that it
might be prudent to see another POTS specialist for an opinion. It might also
turn out to be helpful to see the Rheumatologist and Neurologist to see if they
have any thoughts or ideas.
I know this is beyond frustrating for you,
feeling poorly and not having any therapies pan-out with respect to making you
feel better. There are no clear answers when it comes to POTS.
Best wishes,
Primary Care Physician
Jess’s
reply, excerpted below, takes the doctor on for “surrendering” rather than
trying to coordinate her care:
The majority of my friends are allied with the
healthcare field – doctors, health lawyers, nurses, health administrators – and
all ask “who’s coordinating all of this?” to which I say I am and then they all
stress about who is going to take over when I start puking and can’t get off
the floor on my own.
I’m not sure where they got the notion that
my primary care physician should coordinate my care, maybe they were looking at
NCQA’s patient centered medical homes model, or found a copy of the Accountable
Care Organization regulations from CMS, or listened to people discuss Obamacare
on Late Night with Jimmy Fallon. All I know is that they all say that a PCP is
the person to coordinate care.
In my search to figure out what this actually
means, a physician friend turned me onto Vernon Wilson’s 1969 article entitled
“Prototype of a Doctor.” Wilson postulates that as a continuing medical
advocate for their patient, a PCP’s job is to evaluate and coordinate patient
care and “accept responsibility not merely pass it along – utiliz[ing]
specialists rather than surrendering to them.”
By telling me that my condition is complex
and stating that I should just see additional specialists, you are
surrendering. . . So, this leads me to ask: If you are not willing and able to
help me, who in your practice is?
Best,
Jess
On
November 15, 2014, she added up all of the encounters she had with the health
care system to date--“56 outpatient doctor visits, 20 emergency room visits,
and spent 54 days inpatient”--and how many of these visits were actually useful
to her. I encourage readers of this blog to read her
detailed tables. She
particularly felt that her visits with her primary care physician were the
least valuable:
The only reason Primary Care received any
value attribution is because I need someone to renew prescriptions for anti-nausea
drugs, letters for FMLA, and send records to hematology. I feel bad that their
years of medical school and residency are being wasted on purely administrative
procedures.
Some of these specialties were overly
impacted by the amount of time it takes to schedule visits. For instance,
hematology took six months and over four hours of my life to schedule one
visit; however, the time spent with the doctor herself is quite valuable.
Conversely, Ophthalmology and Endocrinology were scheduled using a third party
platform so the scheduling process was very smooth, but using the third party
platform led to billing issues. If I accounted for the time-value of money, the
numbers would shift a bit.
On
May 31 of last year, she wrote about a hospital stay that she called “the most
profoundly heartbreaking experience of my life”—not just for her, but for the
patient that shared the room with her, excerpted below:
. . . when I answer people asking ‘What is
the worst healthcare experience of your life?’ - that honor belongs to the 48
hours I spent housed in an on-call room last November.
November’s stay made me appreciate my
cellphone in ways that you should not have to appreciate your phone while
inpatient at a hospital. Here my phone wasn’t my connection to the outside
world - it was how I connected the dots within. It enabled me to contact five
of my physicians, all of whom are attending physicians at your institution,
when my resident was unable to do so. When the resident insinuated I had not
established care with hematology, I was able to call the hematology department
and connect my hematologist to the resident in under 15 minutes. At the time of
admission, I had given this resident a typed list of my specialists which
included the same contact information I used successfully; as such I find it
difficult to believe the resident attempted to verify I was an existing
patient.
When the nurses couldn't hear the physical
bells my roommate and I were given, I resorted to calling the nursing station
on my cellphone (Ironically, courtesy of the speaker in the wall of our on-call
room, we heard nurse requests from all the other patients on the floor). My
roommate did not have a cellphone and I ended up relaying her requests by
calling the nurses station each time my roommate rang her physical bell. As
such, I didn't sleep the entire time we were in this closet.
However, these communications issues are
simply annoyances in comparison to the emotional torture of a fellow human
experiencing unrelenting pain.
My roommate, admitted for a Sickle Cell
crisis, cried hysterically for over 12 hours while her pain remained unmanaged.
During this time I called and emailed the patient advocate several times on my
roommate’s behalf and ‘rang’ the nurse countless times. Eventually my roommate’s attending came to
see her. Unfortunately her physician was “Dr. Feelgood.” I had the misfortune
of being this physician’s patient in July. I nicknamed him “Dr. Feelgood” for
stopping my pain regimen (developed by a pain specialist) and insisting yoga
(contraindicated with my joint condition) would magically fix all my problems.
True to form, Dr. Feelgood insisted my roommate's issues related to positive
thinking and refused to revert to a pain regimen that had apparently worked
before. I’m not a physician and have no idea what pain medications this girl
should have been on. But as a human I know that “Tears = Bad” and anyone that
cries for twelve hours while begging someone, anyone, to call their physician
of record isn't faking it. She didn’t stop crying until a doctor with some
humanity sedated her following shift change. The complete disregard for her
pain stripped her of her dignity and brought me to tears.”
Reading
Jess’ posts brings me to tears. How can anyone who has empathy not be?
But
feeling bad for Jess, her roommate, and the many other patients who are failed
by our health care system is not enough.
We who make our livings as advocates for primary care and
Patient-Centered Medical Homes must acknowledge the chasm between the principles we articulate, and Jess’ experience.
Where in Jess's experience was the “ongoing
relationship with a personal physician trained to provide first contact, continuous
and comprehensive care” ?
Where was the “personal physician [who] leads
a team of individuals at the practice level who collectively take
responsibility for the ongoing care of patients” ?
Where was the “Whole person orientation – the
personal physician is responsible for providing for all the patient’s health
care needs or taking responsibility for appropriately arranging care with other
qualified professionals. This includes care for all stages of life; acute care;
chronic care; preventive services; and end of life care”?
Where was the “Care is coordinated and/or
integrated across all elements of the complex health care system (e.g.,
subspecialty care, hospitals, home health agencies, nursing homes) and the
patient’s community (e.g., family, public and private community based services)”?
Where was the advocacy “for their patients to
support the attainment of optimal, patient-centered outcomes that are defined
by a care-planning process driven by a compassionate, robust partnership
between physicians, patients, and the patient’s family”?
Federal
policymakers must also acknowledge and address the gap between Jess’ experience
and the kind of care they would want for themselves and their families, and how
their own regulations and flawed policies may contribute, as Acting CMS
Administrator Andy Slavitt did in tweeting about
Jess. Hospital administrators need to
acknowledge and address how their institutions are failing patients like
Jess.
And
physicians, nurses, pharmacists and other health care professionals must
acknowledge and address the fact that Jess, like so many other patients
including those with more common diseases—have been failed by a system that
doesn’t put patients first. While I
believe that most health professionals care deeply about their patients, and try
to do the best they can, many of them would say that they are stymied by a
“system” that devalues patients’ experiences with the care received. But blaming the system isn’t enough: the
medical profession has an obligation to do everything it can not to surrender
their patients to a system that doesn’t seem to care about them, and to
advocate for reforms to truly put patients at the center of the health care
system.
Most
importantly, we need to listen to patients, including those like Jess who now
speak to us from the grave.
Today’s
question: What do you think of Jess’ experience, and what should be done about
it?
