Photo Source: Photo from Pamela Wible, MD blog post Are You A Victim of Patient Profiling?
I’ve worked in healthcare marketing and market research for more than 20 years. Between all of the brand launches, service line campaigns, market research, patient satisfaction analysis, etc., I’ve spent a lot of time in conversations about the patient experience. And with that, one would think someone with my background would truly understand the cadence of patient/doctor/clinician interactions and the patient journey. Yet, you don’t really get what that looks like until you are not only part of the conversation, but the main focus.
As hospital and healthcare marketers, we often have idyllic thoughts about how physicians and clinicians are talking to patients because we market the “patient experience” as defined by the hospital or the latest brand initiative. We assume they’re showing empathy and compassion, giving the patient all the time they need to ask questions about a condition or even a simple sinus infection. We think patients aren’t being rushed out of the exam room left to feel confused and dismissed. We assume patients are being spoken to in a respectful manner by all clinical staff. Above all, we would like to think that clinicians aren’t making assumptions about a patient’s lifestyle, intelligence level or character purely based on how they look or speak, outside of his or her medical condition. Nor should any of this bias come into consideration when it comes to what a patient “deserves” for his treatment. But that isn’t always the case. Let’s face it, we are all passing some level of judgement on people in the back of our heads until proven otherwise. But the old saying “you can’t judge a book by its cover” rings true in patient care for sure.
In a blog post on patient profiling written by Pamela Wible, MD, she features actual patients who were victims of patient profiling. Physicians assumed, based on how a patient dressed, spoke, conducted themselves, etc. that they automatically fit into a “category.” Therefore, clinicians evaluated and treated the patient differently than a patient perhaps considered to be in a more acceptable caliber. These assumptions spanned anywhere from drug addict to bad mom to stupid and beyond. We all pass judgement. But when we aren’t feeling well or when a loved one is in a life and death situation, the last thing we want is for a physician to get lazy and refrain from pushing as hard and as far as possible to get the answers for a medical issue because of bias and assumptions. Which brings me to my story….
On Father’s Day 2017, my family and I had a late lunch at a casual, well-known burger place in the suburbs. It was a great weather day, so sitting on the deck of the restaurant was a must. Earlier in the day, I noticed I was a little stuffed up. I have allergies, so that wasn’t unusual. I ran out of my regular over-the-counter allergy medication, so I took a Benadryl. A few hours later, I took a couple of ibuprofen for some shoulder pain that I really didn’t want to be bothered with throughout the day. Fast forward to our late lunch, and since I was in a celebratory mood (it was Father’s Day after all), I ordered two Coronas in the course of a few hours. I had appetizers and the best burger ever, so nothing I would consider to be a crazy afternoon on the deck with the family.
I came home early evening and got ready to settle in for my Sunday night to relax before another Monday began. As soon as I sat on the sofa, the room started to spin wildly. I couldn’t stand up, so I laid down in hopes that the rapid spinning would stop. When it didn’t, I called my mom. She came over and we agreed it would be best to call EMS. By the time they arrived, the room was still spinning and I was incredibly nauseated. Once in the ambulance, I had my glucose checked and had a needle stuck in my left arm in case an IV was going to be started. I heard a medic call into the ER with his take on my problem, which allegedly was “vertigo.” Vertigo never crossed my mind, but it seemed this medic was already taking a stab at a diagnosis. Now, I realize medics see all kinds of things in the field, but I think he should have stuck to reporting symptoms. By the time I got to the hospital, the nurse was already telling me that I had vertigo. I asked, “how do you know?” She said, “because when you lift your head, the room spins.” At this point, the team barely had done an assessment and I had not seen the doctor yet. At minimum, I was put into a gown, and hooked up to leads and an IV bag of saline. Finally, after about 45 minutes, the physician’s assistant (PA) comes in to see me. Yes, I got the PA. I am sure many of you have heard about “mid-levels” — clinicians who can do many things a doctor can but isn’t a doctor. They are overseen by a physician, and can prescribe some medications but not all. They save dollars and time basically, particularly for lower acuity cases so that physicians can spend time with more complicated cases. Therefore, for my case, I got the PA and not a doctor.
Finally, I was given a medication for vertigo called Meclizine that controls dizziness and nausea. After I laid there for two more hours and nothing was helping, I asked the nurse to tell me what the plan was since I still felt the same way I did when I came in. The PA recommended another dose. At around midnight, mind you I’d been in the ER since about 7 pm, I was being asked to get up and walk so the nurse could assess whether or not I was stable and balanced enough to go home. I walked through the hallway a bit and even though I was feeling better, I was far from feeling confident enough to manage around the house by myself.
Once the nurse brought me back to the room, I got back onto the bed and I was still feeling miserable. After a few more minutes, the nurse came back and said, “Dr. So-and-So is suggesting that you go home and go to bed so you can sleep off everything you took today.” I, quite irritated, asked, “what exactly do you mean by that?” She replied, “well with the Benadryl, the ibuprofen and the two beers, that’s probably why you feel the way you do. So, Dr. wants you to go home and sleep it off.” Now, if I were feeling better, the skies would have opened and I would have told her what I thought about the recommendation to go home and the doctor’s reason why.
For better or for worse, I know a lot about the inner workings of a hospital from a productivity and finance standpoint. Quite simply, hospitals want patients to be discharged, the sooner the better. And depending on the acuity of your issue, you will get the mid-level or in my case, PA, to keep expenses lower and margins higher. Hospitals want to turnover the room as quickly as possible, and hopefully, a profitable patient will fill it. I was a low acuity case taking up space. My mother then went on to ask the nurse, “how can the doctor discharge her when he hasn’t seen her.” Apparently, the PA already discharged me and the nurse again expressed that it would be best for me to go home.
Well, I was going home with some Meclizine and whatever balance I had at that point. Still feeling awful, I changed back to my regular clothes, the nurse took off the leads and pulled out the needle from the IV out of my arm. I was still highly unbalanced, somewhat dizzy and nauseated, but I was trying to get myself together to be driven home. All of a sudden the doctor saunters into the room and in a very condescending tone says, “what’s going on here?” I explained to him that I was still not feeling well and didn’t feel stable enough to go home. He then questions, “do you think it was because of all that you took today?” Holy O-M-G, Batman!! I could not believe this guy just said that. I went from having paramedic-diagnosed vertigo to being physician-insinuated “substance-mixer girl.” I was so angry to where he did get attitude from both me and parents. The funny thing was that although the nurse in her assessment was told about my allergy pill, the ibuprofen and the two beers during the day, nothing was implied but vertigo and only vertigo nor was any of “what I took” indicated as the cause of my vertigo.
ER physicians, in particular, see the worst of conditions as well as patients and families in their most distraught states. People make bad choices, most are legitimately sick enough to be in the ER and some don’t know how to navigate the system to even know how to find a physician. However, in this case, I believe I was profiled most likely as, “stupid girl who had too much to drink and didn’t stop to think about the medication interactions.” Now, as a pharma, I’ll say it again, pharma, market researcher, trust me, I am more than aware of being careful of medication contraindications. I’m not a doctor but I have a good handle on these things and what to look out for. I’ve never had any issues with Benadryl or ibuprofen, nor with taking them in close range of each other. And as for the alcohol, that was several hours later with a good amount of food. I didn’t see a problem, but as I said I realize I’m not a doctor.
The doctor went on to have me walk so he could see first hand if I was stable enough to go home. His assessment…“I can appreciate the fact that you’re still unstable, so to make sure we didn’t miss anything, let’s get a head CT and get you started on Ativan.” You remember that I was already changed back into my clothes and the IV needle had already been removed. Guess what? Yep, I had to change, have leads put back on and I had to get another needle jammed in my hand for the bag of Ativan.
In the end, the CT was negative and in another two hours later I felt much better. Yet, I was curious as to why the PA didn’t take the Ativan pathway initially, instead of having to lay there for five hours waiting for Meclizine to work. I asked that very question to the nurse and her explanation was “everyone treats differently.” And that was it. The PA gave me the less expensive route no doubt, but was less effective. Instead of going to the physician after the first dose of Meclizine didn’t work, she gave me another round. I could have gone home sooner after the Ativan and “slept it off” a lot quicker.
Needless to say, it was a nightmare evening but could have been worse. Vertigo really is an awful thing I don’t wish on anyone. I finally got home at 3:30 am on Monday. Being analytical and a processor, I thought hard about what these clinicians might have been thinking. I showed up in the ER looking like hell, wearing yoga pants and an old shirt, and no shoes. I was just going to be hanging out on the sofa, so I didn’t care how I looked at that point. But, I could see where the ER team could have and maybe did make assumptions about the kind of person I was and the day they assumed I had supposedly carelessly mixing over-the-counter medications and alcohol. It turns out, according to my ENT, there is no way that one Benadryl, a few ibuprofen and two beers with food would cause vertigo. Most likely, it was an inner ear infection or virus that caused it since I had not experienced any head trauma nor was I doing anything like gardening where my head was down for a long period of time. After an MRI a few weeks later as I had still been experiencing some dizziness and nausea, it turns out I had a severe sinus infection. A month prior to my vertigo episode, I had been taking antibiotics for a sinus infection which apparently never went away and very likely triggered my trip to the ER. So there you go…no interventions needed here.
Although my patient profiling story is not as severe as those Dr. Wible highlighted in her blog post. Rest assured though, this happens every day. And, I wonder how many patients are not getting what they need because of profiling? The moral of the story is, and although cliché, you do need to be your own health “advocate” whenever possible. And if you are unable to speak for yourself, a friend or family member needs to step in. Many people are intimidated by physicians and clinicians, and are afraid to ask questions and push for answers even if they aren’t fully satisfied with what they are hearing or don’t understand the answers. There are still plenty of folks out there that will do what the doctor tells them to do without question. I’m not saying all physicians and clinicians are this way. Most of them innately take their scientist nature and dig for answers. But there are plenty who don’t. They don’t take the time to assess the patient, they misdiagnose, and possibly prescribe the wrong or minimal care. Yet, I stand by the fact that most physicians take the vow of “do no harm” very seriously and are overall well-intended professionals and good people, which is why they chose this calling.
Having worked in the healthcare system for so long, I have had the privilege to work with some of the most renowned physicians and passionate clinicians around. I love medicine, but the process of navigating the system is daunting even for someone like myself with years working in hospitals. It is true that we never really understand what people are going through and shouldn’t assume. I think some situations are obvious, but most are not and it takes a physician or clinician with some degree of empathy and zest for super-sleuthing to figure out what is happening and decide on the right solution yet keep their biases aside. Most clinicians do just that. However, in many ways, I believe the problem is how the system is set up, and how reimbursement works therefore, how margins are affected. My hunch is that some of the profiling that happens, does so for those reasons. The quicker the assessment, the quicker the patient gets treated and discharged, and the sooner a fresh open bed is available for the next patient. But that is the system we live with today and hopefully, in our lifetimes we will see change.
And when I think about the research I do for a living, I keep myself in check to stay open to the patient’s or physician’s context for their lives and the experiences they’ve have which makes them who they are and think the way they do. In research, there’s no room for profiling and making assumptions when we are seeking out the truth.
UPDATE! August 4, 2017 — As an add-on to my article, here is news from Good Morning America’s Dr. Jen Ashton about fat shaming and “size-ism.” http://abcnews.go.com/GMA/video/fat-shaming-doctors-office-harm-patients-study-finds-49025799
Photo from Pamela Wible, MD blog post Are You A Victim of Patient Profiling?
