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1May

The family GP doesn’t do house calls anymore

In late May 2009, my 87 year old mother-in-law fell. She got back into bed and stayed there.

She was unwilling to get out of bed and be taken by ambulance to the ER for an x-ray. The family doctor would not examine her until she got an x-ray. After 5 days in bed, she was ready to die. I took our friend Anna, a geriatrics specialist at the Sheba Medical Center to see my mother-in-law. An examination revealed that she had not broken her hip but was in poor physical condition due to lack of activity and multiple drug interactions. Anna said “Your first order of business is to get her physiotherapy, raise the bed and review her meds”. I raised the bed with bricks from in the back yard and brought in a physiotheropist. I scheduled a visit to the family physician after taking inventory of her meds. This is what she had in the night table:

  1. Eltroxin 100 micro-gram, 1/day on empty stomach, not clear if taking consistently at same time Indications: Thyroid hormone supplement Side effects: confusion, mood swings.
  2. Ikapress (Slow release 240). Indications High blood pressure Side effects: yellowing of the skin, confusion, swollen ankles.
  3. Enaladex: Indications: Treatment of essential hypertension
  4. Aldospirone: Indications: Heart failure, congestive heart failure. Side effects: Mood swings
  5. Teril (Carbamazepine) Indications: Epilepsy and neuropathic pain (mother-in-law has diabetic neuropathy). Use with caution with elderly people with history of history of heart disease
  6. Hilba (Fenugreek) Indications: Mild diabetic condition. Side effects: None.
  7. Bevatex (B-12) Indications: Anemia, neuropathy. Side effects: None.

At the meeting with the family physician, I brought the list. He compared it with the prescriptions in the system and he said “Yep, those are her meds”. I gave him the write-up from Anna and told him that she had many of the side effects documented on the labels (which I got courtesy of Google). I asked why she was taking Teril (it’s not approved by the FDA in the US for diabetic neuropathy) and he said that in Israel it had been found effective, but perhaps I was right and he dropped the dosage by half and removed Aldospirone from the list.

The family physician prescribed a 48 hour Holter monitor test and referred us to the office in Tel Aviv where they would put it on my mother-in-law. He said “Order an ambulance, her coverage will pay for it”. My mother-in-law refuses to get in an ambulance: ambulances are things that take people to hospitals where they die. Understanding that we were at yet another doctor-patient impasse I made a little spreadsheet, printed a few copies and got her Nepalese care-giver, Gonga, to take manual blood pressure readings in lieu of a Holter.

I went back to the family physician with the spreadsheet and he said: “You know, this is very scientific, you can see how the medication stabilizes BP after 2 hours and then drops”. He reduced the Ikapress dosage, prescribed black coffee for late afternoon and cursed his EHR system for not allowing him to override the standard dosages. My mother-in-law’s condition got better; the confusion, mood swings and swollen ankles improved (thanks to physical activity and PT which she still hates). Fast-forward to today (February 2012), she gets around with a walker, sits outside in the backyard, plays cards with Gonga and teaches her Libyan cooking. Her short-term memory is bad but she enjoys the great-grand-children who come to visit even if she forgets their names.

We can use online technology to help people like my mother-in-law get better and help her PCP get her better care.

Visualize  a private social network for a doctor (my mother-in-law’s doctor), patient (my mother-in-law) and care-givers (me, Gonga).

Now visualize Facebook-style interfaces –  a highly effective way to interact with patients without requiring them to come to the office.

Imagine patient-mediated input of data before visits to the office, making the clinical data more up-to-date, accurate and complete and boosting the trust between doctor/healthcare worker and patient.

And finally – how about focusing on improving care by improving data and trust with simple things like:

  1. Simple manual data entry of critical events; for example blood pressure, pulse, dizziness, general feeling, appetite, clarity of speech, movement stability on a timeline, that enables the doctor to respond to changes in a timely fashion.
  2. Reconciling differences between what the doctor ordered and what the patient did.
  3. Private messaging without exposure to email-borne spam and malicious content.Imagine that and you have Pathcare.
  

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