Thursday, March 03, 2005

Annals Internal Medicine cites need for better information system but ignores ignorance of house staff in published case history

In the March 1, 2005 Annals of Internal Medicine the "Improving Patient Care"section deals with a case in the discussion about which the author emphases the problems associated with lack of follow up by and "hand offs" to physicians. A 70 year old alcoholic presents with cough and weight loss.His chest xray showed "RUL pneumonia with a dense infiltrate with extensive fibronodular disease and upper lobe volume loss. No tb studies were done and the patient was discharged on antibiotic therapy.Through a series of lapses it is some 2 months later and after the patient was sent to and then sent back from a nursing home before the diagnosis of tb was finally made and treatment started, but apparently too late. He died of respiratory failure shortly thereafter.
The author discusses various methods to ensure followup . He does not mention, however, a well established method of obtaining follow up of lab tests. It is the RPU. This stands for responsible physician unit. The physician caring for the patient is responsible for finding out what the results of the tests.
The clinical picture and chest film shouted r/o tb. The narrative of sequential foul-ups is disturbing and the author's comments about the important of systems to ensure that reports are seen by doctors are appropriate. However, the original "fumble" occurred because of the apparent ignorance of the medicine resident ( I assume they were medical residents). While the subsequent events are alarming-and may be mitigated or eliminated by appropriate systems and safeguards- the lack of basic clinical knowledge demonstrated in this case is astonishing.
I cannot believe even a first year resident would not think "rule out tb" when he encounters an alcoholic with cough, weight loss and a upper lobe infiltrate. (the initial radiologist's report displays a high level of cluelessness also by not mentioning tb as a diagnostic possibility) Even if the resident was ignorant about tb,where was the attending?Not doing tb tests in this type case is comparable to not doing biomarkers for heart damage in er patients with chest pain.
At the county hospital at which I trained that patient's arrival would have lead to the intern, resident and medical student spending the next few hours getting sputum samples and doing AFB stains. Even if the smears were negative the patient would have likely been hospitalized in a contagion unit to rule out tbc given the very high "pre-test" probability of tb.
The author speaks of algorithms for this and algorithms for that. What is the nature of the algorithm to prevent house officers from harming patients based on their ignorance? In a earlier - less politically correct era- in regard to the first house office who saw the patient- we would have asked where did he go to med school.

2 comments:

Epador said...

We trained in a time when we drew our own blood, prepared our own Gram and AFB stains and ran our own EKG. And were responsible for recording all this in the lab as well as the chart.

I wonder how many house staff these days would recognize the right reagents, much less know how to use them, or even hook up the leads for a 12-lead EKG. God forbid the tracing should come out without a computer generated over-reading...

No wonder they let this one fall through the cracks.

Epador said...

I put his up as a Rapid Review on the AIM site. Doubt it'll stay there.

A succinct criticism and one question:

1) An obvious case of TB that any medical student should have recognized was missed and failed to be treated until it was too late to save the patient. Questions of integrity (an obviously abnormal X-ray reported as reviewed and "normal," apparant lack of competent attending supervision) as well as lack of basic knowledge scream from the paragraphs of this case study.

2) An analysis published in AIM considering this episode fails to address 1) while laying down a smokescreen of secondary, albeit cogent, considerations.

3) This made it through Peer Review?