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My Patient's Care Was Complex. I Tried to Simplify It

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The determination to improve people’s lives. We say that is our motivation when we become physicians. Whether length or quality of life is increased, we hope for a positive result from our efforts.

Cooperative and affable are two words that could be used to describe this patient. His mother, also a patient of mine, had passed away within the last few years. Frank was 61 years old at the time of these events. Approximately 30 chronic conditions, 24 medications, and 13 specialists were noted in his chart.

My newer NP had started following him, so I hadn’t seen Frank in a while. This nurse was independent and trying to prove themselves, so they did not ask me any questions about his case. A review of his chart one afternoon shocked me when I realized how complex his care had become. I dove into his history and meds, on a mission to somehow put it all in order.

His magnesium was low due to chronic proton pump inhibitor and diuretic use. So, he had been started on magnesium supplements. When diarrhea started, diphenoxylate was added by his gastroenterologist.

He was chronically short of breath, presumably from asthma, despite taking prednisone daily. His diabetes was out of control due to the prednisone, and it made adjusting his insulin pump difficult. His cardiologist and the CHF clinic had him on carvedilol and aspirin. His psychiatrist had him on trazodone for sleep and bupropion for depression.

I started by touching base with the patient. I found out he was taking bupropion at night and was also taking hydrochlorothiazide (which had been stopped when bumetanide was started). I called his pulmonologist to see if montelukast, budesonide, and daily prednisone were all necessary. The patient was only supposed to be taking prednisone as needed. Frank became short of breath when I tried to wean him off the prednisone. Since aspirin and carvedilol can sometimes trigger asthma, I got agreement from his cardiologist to change the carvedilol to nebivolol. Going through old records showed his previous pulmonologist had been trying to help his shortness of breath also, so this had been an ongoing problem. The patient audibly wheezed, but it sounded like it was upper respiratory. Granted he had CHF and morbid obesity, but those didn’t account for the wheezing.

Switching his magnesium to slow-release helped his diarrhea, and I was able to get him off diphenoxylate. I found out he was using his budesonide, and I was able to reduce his prednisone when he started using budesonide regularly. His blood sugar improved by going back to prednisone as needed after weaning the steroids off. I set Frank up with a bariatric surgeon, but he was too afraid of surgery to go. Switching bupropion to morning and holding trazodone didn’t work, so trazodone had to be restarted for insomnia. The hydrochlorothiazide was stopped. Getting rid of three medications seemed like a drop in the bucket, but it was a start. The cardiologist added isosorbide soon after that. Although I am sure it was necessary, it felt like I was on a losing team.

After hours of studying his chart, UpToDate, and talking to his specialists, I felt like his medication regimen was at least a little more ideal. The next month, however, news came in that Frank was going to have to transfer his care because he had switched to Medicaid. I was not a Medicaid clinician.

Would his new physician understand why he was taking some of his current medications? Would the Medicaid formulary cause his regimen to be deleteriously altered? Would I have spent so much time organizing and reviewing his medications if I’d known he would be leaving? 

Patients rarely understand whether their treatment regimen is optimal. The PCP is supposed to oversee this, but we rarely have the time. Spending so much time on one patient is certainly not part of my normal routine. I know NPs don’t always feel comfortable coordinating with specialists. How many PCPs also feel that they are stepping on toes when they question medications? The collaboration effort will hopefully be streamlined one day, but for now, it takes a lot of time and effort. EMRs could certainly be used more efficiently for this purpose.

The truth is, I am not sure I would do it all again for a patient who was transferring to another clincian. “Let them handle it,” might have been my motto. We can’t predict the future of our present efforts, but we do learn from each case.

Kara Wallace, MD has been in private practice for 20 years. She is a Family Physician in Huntsville, AL. Pre-med and NP students have rotated through her clinic as part of their school curriculum.

All names and identifying information have been modified to protect patient privacy.

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