Failure of communication led to an excessive hospital stay

On a late afternoon in mid-July I was finishing up my first Sunday on call as a third year medical student. I glanced over the patient list for 4 East, the internal medicine floor I had been assigned to cover. Familiar with patients in their eighties and nineties, I was surprised to see a 22-year-old patient admitted with acute kidney injury.

He was a nice-looking young man in good spirits. Spanish was his first language, but he could converse pleasantly in English, stating that he felt “good.” I palpated his abdomen and listened to his heart and lungs. He reminded me of my own 21-year-old brother, and I could easily imagine him throwing back some beers with friends or tossing around a football. He worked for a roofing company and had been subject to the sweltering Chicago heat for the last six days. The emergency department had surmised that his acute kidney injury was caused by severe dehydration. My internal medicine residents agreed and we began loading him with fluids. This was day two of Garcia’s hospital stay.

On Monday morning, Garcia continued to deny any complaints. His blood pressure was high at 150/80, despite treatment with medications. Creatinine, a marker of kidney function, continued to be abnormally elevated at 4.1. Ultrasound imaging showed evidence of a complex cystic mass in the kidney, along with areas indicative of chronic kidney disease. Multiple test results were pending to figure out the cause, including a comprehensive immunology panel. The nephrologists consulting on his case recommended a kidney biopsy, and a follow-up ultrasound and CT scan, finding Garcia’s previous imaging results inconclusive.

On hospital day four, Garcia’s blood pressure remained elevated with kidney function stable but poor. On day five, the nephrologists ordered vein mapping in case the need arose for hemodialysis. The team suspected chronic kidney disease secondary to nephrotic syndrome; a biopsy would confirm this diagnosis. Day six was a lot like day five, except someone checked the urine for protein. At 6.5 grams per 24 hours, Garcia had nephrotic range proteinuria. This is when I found out that Garcia was a self-pay patient and thus unable to afford a biopsy.

The case manager suggested we discharge home and recommend he follow up at the county hospital. Unfortunately, County doesn’t take transfers. So, Garcia would have to start at the beginning by seeing a primary care doctor during clinic, and be referred to a nephrologist on staff. While this would save Garcia significant money, the case manager worried about losing track of him. Despite his worrisome blood pressure and lab values, he felt great. Daily, he denied any complaints and smiled pleasantly throughout physical exams.

Days 7, 8 and 9 followed. Garcia’s blood pressure gradually normalized, but his kidney function remained very poor. The medicine we originally used to treat his proteinuria caused elevated potassium and uric acid, so we had to discontinue it. His hemoglobin dropped, either due to the kidney disease, or because we were loading him with IV fluids. It wasn’t clear if our interventions were helping or hurting. So, we just watched him for three days while waiting for Nephro to sign off on the case so he could be discharged.

On day 10, Garcia’s bed was empty. The case manager shared that he had finally been discharged. The immunology workup still pending, they promised to alert him to the results when available. He was instructed to look into programs that would help pay the cost of dialysis.

During Garcia’s hospital stay, he received competent medical treatment. However, patient care was lacking. The failure of communication lead to an excessive hospital stay and thousands of dollars the patient clearly could not afford. There did not appear to be an open line of communication between the primary doctor, the nephrologists, the case manager and the patient’s family. By day three, the patient was stable. Why did he stay an additional six nights in a hospital bed he could not afford? There was no need to observe the patient while waiting for the immunology panel that typically takes 2-3 weeks to process. Did the physicians not know he was a self-pay patient? If aware, would it have changed their treatment plan? Perhaps the nephrologists wanted to “solve” this unusual case. Why did it take them so many days to sign off on the patient? And, given the language barrier, did Garcia’s family understand the suspected diagnosis and prognosis? With better communication, these obstacles to cost-awareness could have been avoided and improved Garcia’s outcome.

Kelly Donovan is a medical student. This post originally appeared on Costs of Care.

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  • http://twitter.com/IrajAgatsteinMD ira agatstein

    Do Hospitalists have an incentive to communicate generally not time effecient a liaison would be best

  • http://pulse.yahoo.com/_2WONKQFJFWODXGEY53YC3A3NUA JaneQ

    I am horrified that this piece is written by a medical student. If the only going concern is the how much care a patient can afford, and not a diagnosis, you and others like you are in the wrong profession. As I read the article, I grew increasingly frustrated with the lack of a definitive answer to what was wrong with the patient. This is typical of so many cases these days. Perhaps the nephrologists did want to solve the unusual case, so how is that a reason for criticism? It is more than the rest of you thought of. For ten days of ‘observations’ and tests you people had no answers. Then you sent the guy home with instructions to look into the costs of dialysis. You argue that the patient could not afford to stay so many nights, what is it, a five-star hotel? Would he be better able to afford death from lack of care? And if he was stable on day 3 why was a vein mapping required on day 5 “in case the need arose for a hemodialysis”? So as long as we can sign off that he was stable at discharge, we don’t care about anything else?
    As doctors it is your duty to heal, you should be concerned more about the fact that medical science has such few answers to begin with, and no answer that isn’t a slave to insurance billing. The problem is the rising cost of care, not that the patient couldn’t afford the care. You and other doctors should be protesting against the fact that rising costs prevent you from doing what your calling demands – heal the person who comes to your care, you are not supposed to be held back by someone’s financial situation. And if it’s not a calling, just a job, find employment in the medical billing industry. I am shocked that instead of lamenting the fact that all you needed was a biopsy to confirm the diagnosis, and you couldn’t do one because of your insurance or the lack thereof, you bemoan the fact that he stayed too long.

    PS: there are many reasons why he said he felt good – because he was polite and prone to good spirits, because he had greater tolerance of discomfort, because he recognized that you were trying to help him, and perhaps you didn’t consider the fact that even he knew he couldn’t afford to stay and so was underreporting his condition.

    • southerndoc1

      Don’t criticize the med students. 

      The corporate-medicine attitude now pervades their education and learning environment from day one. Learn to deal with it: this is only going to get much, much worse.

      • http://pulse.yahoo.com/_2WONKQFJFWODXGEY53YC3A3NUA JaneQ

        I’m not just criticizing the med student, I’m criticizing everyone including their teachers and everyone else that contributes to this situation. corporate has nothing to do with healing which is what being a doctor used to be about. medicine is about more than just prescribing the latest one.

        Seriously, if one is a doctor, what is the reason or justification for continuing to be one if one cannot make them well? And if one cannot make them well, why isn’t more being done? There has to be more to science funding than just a quick return on pill sales, what about saving lives? Or has everyone forgotten that good health is one of the things money really can’t buy?

        Please don’t get me wrong, I hold doctors in very high regard, which is why this is all the more disappointing.

        • southerndoc1

          I think I agree with what you’re saying.

          Medicine is now big, big business. Patients and physicians are just overhead.

    • http://www.facebook.com/mhoggorourke Maryalice Hogg-O’Rourke

      I live in a majority Hispanic part of the country, and worked at a local hospital for 10 years. The vast majority of Hispanic men will say they are well, even the oldest of men, to think that a 22 year old Hispanic man will say he is sick is unrealistic at best.
      He will not “look up” dialysis or present for follow up. Put yourself in his shoes, say you went to Russia for a trip and developed CKD, you don’t know the language or the medical system, you’re in the hospital, with a limited ability to speak Russian and discharged with the instructions to look into dialysis. at age 22 and  with the cultural and language problems, I don’t think any of us would be able to do so.
      I think all medical students should have to take classes in cultural differences.
      It’s a very sad situation.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    It is unclear why the patient presented to the hospital in the first place?  Strange article in which costs and payments seem to be paramount in the authors mind when the real question should be how do we make this patient whole again? Who was the advocate for the patient?  If this is the direction of academic medicine it is a sad future

  • http://www.facebook.com/profile.php?id=734366456 Brenda Adler

    I’d say this is pretty much an argument for a single-payer system.

    That’s no way to run a medical system, the first hospital is probably never going to see most of that money.  To go to a hospital that takes his “insurance” he has to go home and then see two more doctors, which is an unnecessary expense and probably those two doctors have other patients who could use their time more.  And what if this person doesn’t follow up, what are the costs to society going to be then? 

    Also 9 days and they couldn’t find a translator or bilingual patient advocate.  Really?  He spoke Spanish; not Balinese.

  • http://profile.yahoo.com/BRDB4JQJCWCARQUXHEBJBSGNSE arnold

    Communication is the lost art of medicine. It is easier in today’s level of technology to socialize via cell phone, than to discuss meducal care. It is what it is, or is it?

  • katerinahurd

    Do you think that lack of communication might lead to over- or under- treatment of the patient and thus violate to the first principle of medical ethics:  First do no harm.