When a patient tries to get a doctor to focus on his or her specific situation, the least helpful words from the doctor are: “It’s hospital policy…” Add the doctor’s effort to calm the patient with “I understand your frustration,” and then combine it with the physician’s admission: “I haven’t reviewed your file.” Now try to restrain yourself as it becomes clear that she has no intention of ever doing so.
The VRE Mystery
In “Computerized Information Overload,” my VRE blood infection illustrated the problem of overwhelming health care workers with too much patient information. A few days after my post, a doctor’s essay in the Sunday New York Times reaffirmed more generally my observations about the problem.
In my living example, during my third hospitalization I contracted a blood infection — VRE — almost certainly as a result of minimally invasive procedures to stop a pesky GI bleed. Powerful antibiotics squashed the infection and I went home. When I showed up a week later in the emergency room, they put me in isolation. I had no idea why until 10 days later, when my nurse told me that my record showed that I had a history of VRE.
That evening, another nurse undertook a comprehensive view of my file and concluded that I never required isolation because the VRE infection was blood-based. The sign on my door came down; those entering my room no longer downed flimsy disposable “isolation” gowns.
Problem solved? So it seemed. For the next five days, no health care worker visiting me wore the plastic blue gowns.
On the sixth day, another nurse showed up wearing an isolation gown.
“I’m here to do your rectal swab,” she said.
“Why?” I asked. “Last week, a nurse went through my file to discover that I had a blood infection VRE. It’s been gone for weeks.”
“I’m just following the directions I got from the infectious disease nurse,” she said.
After I explained the backstory, my nurse acknowledged the confusion: “I’ll have the infectious disease nurse call you.”
“No,” I said. “Not a nurse. I want to talk to the infectious disease attending physician. Let’s straighten this out once and for all.”
An Incredible Conversation
About 15 minutes later, the phone rang.
“Mr. Harper, I’m the infectious disease doctor,” said the voice on the other end. “I understand you have some questions about our isolation policy.”
“No,” I answered. “I have a problem with the confusion surrounding the handling of my situation. I don’t know how familiar you are with my case.”
“I’m not familiar with your case at all,” came her stunning admission. “I haven’t reviewed your file.”
“I just want to explain to you what our policy is. When you have a positive VRE, you have to test negative by rectal swab for three consecutive weeks before you are removed from isolation.”
“Well, the fact that you’re not familiar with my file is the whole problem,” I said. “There’s no continuity of care in this place and important information about me is not getting through.”
I then explained my situation to her. She listened, and then responded as if she hadn’t heard a word I’d said.
“I understand your frustration,” she said. “But you understand that we have hospital policies to protect health care workers from transmitting VRE. We follow national guidelines in that respect. Hospital policy requires that you have three negative swabs — each one a week apart — before you can be removed from isolation.”
“Well, in my specific case,” I said, “about which you have told me you know nothing, you’ve already blown two other hospital policies,” I said. “No one swabbed me a week after my admission.”
Silence on the other end of the phone.
“Then, five days ago, my nurse determined that I never had VRE for which a swab is appropriate. She removed the isolation sign on my door. Every health worker since then has entered my room without putting on a disposable gown. So there’s policy violation number two.”
“You were in isolation because of your history of VRE,” she responded. Now she was talking in circles. “It’s up to the individual initiative of the nurse to take swabs that get patients out of isolation.”
“Are you an attending physician?” I asked. She said she was.
“Do me a favor,” I said as I concluded my losing battle. “In a quiet moment, I want you to reflect on this conversation. I don’t care whether I get swabbed. That’s not the point. The point is that you haven’t reviewed my file and you have no idea whether the policy you’re defending has anything to do with me, the patient.”
I hung up and summoned the nurse.
“I give up,” I admitted. “Go ahead and swab me.”
After the standard 72-hour period for processing the culture, the lab hadn’t posted the results. Day four: still nothing posted and none of the nurses could figure out why it was taking so long. Finally, five days after the swab and as I was getting discharged from the hospital, I asked the resident to see if the lab had posted the results.
“Here it is,” he replied as he viewed the computer screen. “It says ‘Rare VRE.’ I think it means ‘not very much.’ But the next time you come back to this hospital — hopefully never — it will carry forward to show that you’re VRE-positive.”
I didn’t care. After 19 days in the hospital — bringing my cumulative in-hospital tenure to 43 of the prior 60 days — I was going home.
By the way, lest you think that I have only bad things to say about America’s medical care delivery system, my next post will discuss its best feature: the outstanding health care workers who change patients’ lives for the better.