When patients don’t get the care they should

During the COVID-19 pandemic, nearly all primary care clinicians have been engaged in telemedicine. Telemedicine visits have certain ­advantages—especially convenience to patients. But there are dangers, as well. The ­following true story illustrates one of the important dangers.

The outcome might have been much different if there had been further delay.

“I had an interesting experience late last week that reminded me how important it is to be one’s own advocate in health care. I cut my foot going for an outdoor swim. It got infected so I had a telehealth visit with a physician assistant. She prescribed an antibiotic. The next day, Friday, the swelling and redness were rapidly moving up my foot. I called the office twice. I sent a picture of my foot. No call-back.

I texted my podiatrist the same photo with the question: Do I sit tight or go to the ED? A half hour later, he called me: Go to the hospital. I did. I got IV antibiotics and a tetanus shot. I was also told by the ED doc that my itchy palms were a reaction to the antibiotic I’d been prescribed, and that the physician assistant shouldn’t have prescribed a sulfa drug, given that my chart listed a past reaction to sulfa eye drops.”

The patient is a top-flight triathlete and the editor of JFP, Marya Ostrowski. She was gracious to share her story with us, and she did recover uneventfully, although the outcome might have been much different if there had been further delay.

Her story has 3 important teaching points:

1. We must ensure that our office phone system prioritizes calls from patients. If there is any hint that the problem is urgent, it must be handled immediately.^a
2. CAREFULLY check for allergies before prescribing medication. Perhaps the physician assistant did check the medication list and noted an allergy to eye drops but did not zero in on the fact that they were sulfa. Medication allergy lists can be misleading because they can be too specific. Had her medication allergy been listed as “sulfa medications,” rather than the specific eye drop, the physician assistant may have recognized the allergy correctly.
3. Finally, and most important in my estimation: Patients must act as their own health advocates. Patients are the final common barrier against medical ­errors and we must learn to listen to them carefully. We should encourage our patients to report problems and irregularities in care.

^a The physician assistant returned Marya’s calls at 4:30 that Friday afternoon—8 hours after her first outreach. Marya was already in an ED bed and the nursing staff was starting her IV.

During the COVID-19 pandemic, nearly all primary care clinicians have been engaged in telemedicine. Telemedicine visits have certain ­advantages—especially convenience to patients. But there are dangers, as well. The ­following true story illustrates one of the important dangers.

The outcome might have been much different if there had been further delay.

“I had an interesting experience late last week that reminded me how important it is to be one’s own advocate in health care. I cut my foot going for an outdoor swim. It got infected so I had a telehealth visit with a physician assistant. She prescribed an antibiotic. The next day, Friday, the swelling and redness were rapidly moving up my foot. I called the office twice. I sent a picture of my foot. No call-back.

I texted my podiatrist the same photo with the question: Do I sit tight or go to the ED? A half hour later, he called me: Go to the hospital. I did. I got IV antibiotics and a tetanus shot. I was also told by the ED doc that my itchy palms were a reaction to the antibiotic I’d been prescribed, and that the physician assistant shouldn’t have prescribed a sulfa drug, given that my chart listed a past reaction to sulfa eye drops.”

The patient is a top-flight triathlete and the editor of JFP, Marya Ostrowski. She was gracious to share her story with us, and she did recover uneventfully, although the outcome might have been much different if there had been further delay.

Her story has 3 important teaching points:

1. We must ensure that our office phone system prioritizes calls from patients. If there is any hint that the problem is urgent, it must be handled immediately.^a
2. CAREFULLY check for allergies before prescribing medication. Perhaps the physician assistant did check the medication list and noted an allergy to eye drops but did not zero in on the fact that they were sulfa. Medication allergy lists can be misleading because they can be too specific. Had her medication allergy been listed as “sulfa medications,” rather than the specific eye drop, the physician assistant may have recognized the allergy correctly.
3. Finally, and most important in my estimation: Patients must act as their own health advocates. Patients are the final common barrier against medical ­errors and we must learn to listen to them carefully. We should encourage our patients to report problems and irregularities in care.

^a The physician assistant returned Marya’s calls at 4:30 that Friday afternoon—8 hours after her first outreach. Marya was already in an ED bed and the nursing staff was starting her IV.

During the COVID-19 pandemic, nearly all primary care clinicians have been engaged in telemedicine. Telemedicine visits have certain ­advantages—especially convenience to patients. But there are dangers, as well. The ­following true story illustrates one of the important dangers.

The outcome might have been much different if there had been further delay.

“I had an interesting experience late last week that reminded me how important it is to be one’s own advocate in health care. I cut my foot going for an outdoor swim. It got infected so I had a telehealth visit with a physician assistant. She prescribed an antibiotic. The next day, Friday, the swelling and redness were rapidly moving up my foot. I called the office twice. I sent a picture of my foot. No call-back.

I texted my podiatrist the same photo with the question: Do I sit tight or go to the ED? A half hour later, he called me: Go to the hospital. I did. I got IV antibiotics and a tetanus shot. I was also told by the ED doc that my itchy palms were a reaction to the antibiotic I’d been prescribed, and that the physician assistant shouldn’t have prescribed a sulfa drug, given that my chart listed a past reaction to sulfa eye drops.”

The patient is a top-flight triathlete and the editor of JFP, Marya Ostrowski. She was gracious to share her story with us, and she did recover uneventfully, although the outcome might have been much different if there had been further delay.

Her story has 3 important teaching points:

1. We must ensure that our office phone system prioritizes calls from patients. If there is any hint that the problem is urgent, it must be handled immediately.^a
2. CAREFULLY check for allergies before prescribing medication. Perhaps the physician assistant did check the medication list and noted an allergy to eye drops but did not zero in on the fact that they were sulfa. Medication allergy lists can be misleading because they can be too specific. Had her medication allergy been listed as “sulfa medications,” rather than the specific eye drop, the physician assistant may have recognized the allergy correctly.
3. Finally, and most important in my estimation: Patients must act as their own health advocates. Patients are the final common barrier against medical ­errors and we must learn to listen to them carefully. We should encourage our patients to report problems and irregularities in care.

^a The physician assistant returned Marya’s calls at 4:30 that Friday afternoon—8 hours after her first outreach. Marya was already in an ED bed and the nursing staff was starting her IV.