Bad medical care: Is it better than none at all?

In my past few shifts in the emergency department, I have seen the following patients who were seeking further care after being treated by other providers.

One was a child who had been seen twice at an urgent care clinic. He had a fever of 103 degrees and wasn’t eating. The first time he went to the urgent care center, he was diagnosed with an ear infection. He was started on amoxicillin and sent home. He returned to the clinic 8 hours later because he still had the fever and still wasn’t eating. When the clinic provider looked in his mouth, he saw a red rash that appeared to be an allergic reaction. He was therefore changed from amoxicillin to Biaxin and started on Benadryl. The parents were concerned that his allergic reaction may get worse, so they left the urgent care clinic and came directly to the emergency department.

When he came to the emergency department, he still had a fever, his ears looked fine, and he had the typical enanthem of herpangina. We stopped the antibiotics, stopped the Benadryl, gave the child some stronger pain medication, and had the parents feed him popsicles and cool liquids.

Another patient had been in a bar fight several days prior. He had a cut on his knuckle and his knuckle was starting to hurt. He went to another emergency department and saw a provider who washed out the cut, started the patient on amoxicillin, and then put packing in the wound.

When he came to our emergency department, we started IV antibiotics, removed the packing … from the joint … and sent the patient for surgery to clean out the infected joint and to repair the lacerated tendon.

A third patient had been to both an urgent care clinic and an emergency department for evaluation of palpitations. The urgent care clinic diagnosed the patient with anxiety and discharged the patient with a prescription for Xanax. When the Xanax didn’t help and the palpitations were causing worsening shortness of breath, the patient went to an emergency department. There the patient was seen by a provider who performed an EKG and did a drug screen. The patient was told not to drink caffeine and given a refill for Xanax.

When she came to our emergency department, an EKG showed Wolff Parkinson White syndrome. We got a copy of the EKG from the prior hospital and it showed the same thing. Their EKG even said “Ventricular pre-excitation, WPW pattern” on it.

Finally was the patient in his 70s who was seen at another emergency department for evaluation of abdominal pain and no bowel movement for a couple of days. He had some lab tests done and the provider performed a rectal exam which showed that he had a lot of soft stool in his colon. So the patient received an enema and was discharged home with a diagnosis of constipation. He was told to take laxatives and eat more fiber.

When he came to our emergency department by ambulance later that evening because he vomited the Milk of Magnesia, his abdomen was swollen and tympanitic. He had low blood pressure, no bowel sounds, and a sigmoid volvulus with an obstruction on x-ray. He also went straight to surgery.

I understand that it is considered bad form to question the care of other practitioners. If another provider’s care is criticized, often the criticisms are met with allegations of elitism and hindsight bias followed by a plethora of anecdotes about how those commenting were able to catch some other provider’s mistakes.

You don’t know which patients, if any, were seen by physicians and which patients, if any, were seen by NPs or PAs or medical students. So step back and look at the bigger picture.

In each of the cases above, a patient required multiple medical visits to diagnose and/or treat a problem that should have been apparent on the initial examination. In at least one of the cases, a patient probably had a worse outcome from the initial treatment rendered. Perhaps some people will disagree with me on one case or another. Fine. Assume I’m right.

Providers who may not be as adept at picking out subtle (or not so subtle) findings on a patient’s physical exam and who may provide less than adequate medical care are more commonly being placed in positions of first contact with patients. 57% of all Italians fear being harmed by physicians and 44% disapprove of their national health care system. In the wake of Obamacare, should patients adopt more of a “caveat emptor” approach toward health care?

Pick whatever definition of “bad” that you want. Is bad medical care better than no medical care at all?

If a problem exists, how do we fix it?

WhiteCoat is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly and Dr. Whitecoat.

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  • Suzi Q 38

    Bad medical care is at times harmful to patients.
    With this idea in mind, I would rather not have care at all.
    I’ll take a chance on the body naturally healing itself.

    Between the jaded and bad doctors and Big Pharma, natural healing does not sound bad.

    • Becky

      Speaking of nonconventional, have you seen a chiropractic neurologist for your neck problem? I talked to you months ago through these comments. I am the commenter with severe spasticity and chronic pain following a car accident. I have had amazing pain relief by seeing a special type of chiropractor, called a “chiropractic neurologist.” The results have been miraculous for me. If he can help me, even with my brain damage from being born with cerebral palsy , maybe you can get some pain relief too. I actually have range of motion in my neck now! And he accepts insurance. Google American Chiropractic Neurology Board to find one.

      • Suzi Q 38

        Thank you!
        I will check it out, as I am open to new ideas.

        • Becky

          Fyi, Chiropractic neurology is also known as functional neurology.

        • querywoman

          Ya never know, Suzi Q.

  • John C. Key MD

    WE have all been there, done that if we have been at it long enough. It is always easy, tempting, and fun to criticize the doctors at “Elsewhere General” but don’t think for a moment that they don’t have a tale or two to tell about YOUR emergency department also. What goes around comes around. Karma. Bad luck. Bad care. Call it whatever you want, we all make mistakes. I do. You do.

    Don’t be so smug. Your day is coming if you stay at it long enough.

    • iphone12

      Dr Key, the issue isn’t making mistakes. My PCP recently made an understandable one but she is still my doctor.

      Obviously, I can’t say this happened regarding the situation that whitecoat described but many patients are grievously harmed by doctors due to preconceived ideas such as seeing a mental health diagnosis in their charts and blaming everything on that.

      Or adverse events happen because of the arrogance of your colleagues and not listening to the patients. I know of one person whose 15 year old son died after routine surgery because of this. The professionals couldn’t be bothered to take an extra minute to investigate her concerns even though she tried desperately to communicate that something wasn’t right.

      • rbthe4th2

        That is partly our story also. Multiple times a doctor who blew me off and called me crazy, on several occasions other doctors picked up what he didn’t. All for ego and not listening.

        If doctors want us to put trust and faith in them, its time they started doing something about it to regain that and also trust us.

  • Gibbon1

    My take all of these anecdotes is to bolster my theory that the main problem is the insurance companies forty year old war on primary care physicians compensation. And they ‘won’ so now doctors can’t ‘afford’ to see patients for more than a few minutes. That’s simply not enough time for a doctor to diagnose anything. Primary care takes it in the *** because they have little representation on the Medicare Payment Advisory Board.

    If we want to fix things then fix primary care doctors compensation. I don’t think Obamacare does this, but it isn’t the source of the problem.

  • buzzkillerjsmith

    Better than none at all. Remember the old saying: Dyspareunia is better than no pareunia. At least that’s what they tell me.

    • TheresaWillett MDPhD

      Oh SNAP!

  • Kaya5255

    I think most, if not all, practitioners subscribe to the “when you hear hoof beats… think horses, not zebras” philosophy of treatment. You treat that which is the most obvious.

  • Karen Ronk

    I can state with absolute certainty that bad care can be worse than no care. I should have lived with that pain in my arm and avoided the completely preventable nerve damage done during shoulder surgery. And with no exaggeration at all, I can say that most people I know have some variation of the stories told in this article. As another piece on KevinMD discusses, there are too many “mistakes” made and too many patients are suffering. And to justify or rationalize all of them is just dishonest. We all deserve better.

  • W Joseph Ketcherside, MD

    Oh yeah, Obamacare caused providers to miss diagnoses. Been around over 30 years, and health care has always been caveat emptor.

    • Lisa

      Totally true. The bit about Obama care could have been left out. Then a real discussion about missed diagnoses could take place.

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