The past two weeks I’ve been the “dayfloat” resident on the cardiology inpatient service. With the 30-hour-shift work “restrictions” placed on medical residents, there has been a need for new systems of care to ensure the safety of newly admitted patients and cardiology dayfloat is one of them. My job is to round with the post-call team, help them get out of the hospital on time, and then take care of their patients through the end of the work day. It’s a fairly easy rotation, as they go, though because I “float” from one team to another without patients of my own, it’s also not the most satisfying.
Towards the end of my two week rotation, I was paged by a nurse because a patient’s husband wanted an update on his wife’s condition. Glancing at my “signout” — a one-page synopsis of the patient’s presenting illness and hospital course — I learned that Mrs. FN (as I will call her) was admitted to the hospital for heart failure secondary to “medical noncompliance.” It appeared that she had not had any of her medications for well over a week, which likely precipitated the shortness of breath and fluid overload that led to her admission. On top of this, the patient had a number of “dietary indiscretions” including eating Chinese food, which likely only exacerbated her condition.
Patients like Mrs. FN are not unusual by any means. Heart failure exacerbation is one of the most common reasons for admission at my hospital, and one of the most preventable. Though acute heart failure can be caused by many things, more often than not a patient goes into heart failure because they don’t take their medications as prescribed or because they consume excess salt. Sometimes this lapse in patient adherence is apparent from the beginning — as in Mrs. FN’s case — other times it comes out during the course of the hospitalization or is assumed by the health care team after “medical reasons” such as a heart attack or arrhythmia have been ruled out. Regardless, it is a common source of frustration for doctors who lament that patients “don’t do what they are supposed to do.”
As I walked into the patient’s room, I prepared myself to answer the typical questions families ask about their loved ones: “What did the test show?” “Did she have a heart attack?” “When might he be able to go home?” But Mrs. FN’s husband had a different set of concerns. He wanted to talk to me about the swelling in his wife’s legs. It was making it difficult for her to walk, and taking long walks together was a favorite past time of theirs. He wanted to know why the swelling was there and whether it’d go away. She’d been in and out of the hospital multiple times in the past few months but the swelling kept coming back.
I explained that the swelling, or edema, was due to her heart failure. Whenever her heart failure acted up, the swelling would get worse.
I was planning on leaving it at that but Mr. FN was persistent. He wanted to know how the swelling got there in the first place.
Though I wasn’t sure how much Mr. FN wanted to know or knew already, I decided to answer his question fully. I sat down and explained how in heart failure the heart doesn’t pump blood forward very well. Sensing less blood flow, and thinking that perhaps the body was losing blood or was dehydrated,, the kidneys start holding onto salt and fluid. The more fluid however the kidney hangs onto, however, the more overloaded the heart gets. The more overloaded the hearts gets, the worse it pumps blood forward. This causes the kidneys to hold onto even more fluid, and so on goes the vicious cycle. In the process of building up this fluid, the legs get swollen causing Mrs. FN to have a hard time walking.
Far from being glazed over, his eyes looked at me intently. Clearly, he wanted me to go on.
“Lots things can set off this vicious cycle. If you eat too much Chinese food, which has loads of salt, your body will hold onto water. This water can then overload the heart, decreasing blood flow to the kidneys. The kidneys then hold onto more water, which gets the cycle going again. Not taking your medications can also set the whole cycle off. That’s because each medication acts on a particular part of this system. Take your wife’s lisinopril medication, for example, which works to block the kidneys from holding onto fluid.”
The conversation went back and forth like this for the next 15 minutes. By the end, we had gone through all of Mrs. FN’s medications, explaining the role each one played in his wife’s leg swelling. We also covered the dangers of salt and explained how it’s not just the salt you add at the table but also the salt that is already in foods that can set off the vicious cycle. To really control salt intake, they needed to stay away from processed foods, frozen dinners, and restaurant meals, which only left room for home cooked meals. He even got to talking about why I thought so many people had heart failure, leading Mr. FN to conclude that “it’s all because we want the convenience of cheap, easy food.”
On my way out, Mrs. FN and her husband told me that no one had ever told them how important it was for her to take her medications and eat a low-salt diet or explain why she was on the treatment regimen she was on. At first, I couldn’t believe that she never received this basic health education, but the more I thought about it the more I realized how such a gross oversight could have occurred. Often patients are first diagnosed with heart failure after they present to the hospital short of breath or with chest pain. Having seen a number of “new onset heart failure” admissions during my two weeks on cardiology, I had a sense of how they went.
Patients are put through a battery of tests including blood work, a series of EKGs, an echocardiogram, stress testing, and often a cardiac catherization and at the same time started on 3-5 heart failure medications. Patients, and sometimes even the cardiology team, can barely stay on top of all the tests and new medications that counseling about heart failure is often left by the wayside. In the clinic where this patient would be seen next, the cardiologist is often busy piecing together the history from the patient and scattered hospital records and reconciling medications. Again, the focus would fall on changing medications and filling out prescriptions, and less on providing basic heart failure education.
During the patient’s primary care visit, the doctor may well assume that the cardiology issues are being addressed by the cardiologist and instead focus on the dozens of other issues he or she needs to attend to in their 15-minute office visit. On the patient’s next admission to the hospital for heart failure, he or she would no longer be a “new onset heart failure” patient. The battery of tests would be simpler, but often, as was the case for Mrs. FN, the team doesn’t provide formal heart failure education because they assume the patient has heard it all before.
It is easy to think of simple solutions to this problem but also how easily these solutions might fail. For example, we could simply require all patients admitted for heart failure to be counseled about their disease before discharge. These requirements however are often simply instituted as a checkbox doctors or nurses have to fill before discharge. Thus a patient who is counseled for an hour by a dedicated heart failure specialist and a patient who was told “remember to take your medications” as they were wheeled out the door would receive the same check mark. However, using a more patient-centered approach may be more effective, such as requiring that patients be shown a 10-minute video on heart failure before discharge.
Of course, much of it comes down to money. Hospitals can charge for specialist consultations, echocardiograms, and stress tests; but they can’t charge for heart failure education. Some people may take the cynical view that nothing will improve until reimbursement rules change. (Hang onto your hats — rumors has it that new rules making hospitals financially responsible for heart failure readmissions within 30 days of discharge are not far off.)
It turns out that just as “common sense is not so common,” so is it that “basic health education is not so basic.” We are better at getting patients stress tests and cardiac catherizations than educating them about their diseases. Though I only had two more days of cardiology left, I made it a point to see patients who were admitted for heart failure and provide some rudimentary heart failure counseling. But until we find a systematic way to make tailored health education part of a patient’s standard medical care, we’re likely to keep leaving our patients behind.
- Shantanu Nundy, M.D.
*This blog post was originally published at BeyondApples.Org*