Healthcare Reporters: Please Explore Causes of Dismissive Care

Because I follow the maternal mortality rates in the United States and write about how to bring these rates down, I read many news stories about problems pregnant women have in connecting with the care they need. I find one of the most often told stories pregnant women tell is how they tell whoever sees them about their concerns when they go to the clinic, hospital, or emergency room only to be told nothing is the matter with them and they are sent home.  While I must give credit to reporters who write these articles, I often find there isn’t enough information provided to figure out why the patient’s complaint was dismissed. One could say, “Well who cares, the public won’t understand anyway,” but I’m not so sure these stories need to be “dumbed-down” for the public. As a physician with fifty years of writing and reading medical records, I find myself looking for content and context.

It seems to me that the whole point of writing these articles is to bring the problem out in the open so readers can not only protect themselves from the dismissiveness, but also the problem can be identified for correction. For example, in one story I read, a woman developed a pain in her left calf. We are not told anything more about her symptoms or how long she had them before seeking medical help, whether she saw her doctor or some other healthcare provider, whether she was she ever examined, whether there were any lab tests done, or whether there was any treatment before she was sent home. Information about all of these questions are needed to get the whole story, the context, so readers may understand how the healthcare got derailed by dismissiveness.

The woman in this story later had a C-section at 28 weeks. Why? Certainly, a C-section at 28 weeks is NOT the treatment for a DVT in the left calf.  Did the woman have some other problem such as preeclampsia, eclampsia, hypertension, or preterm labor? This information is not included in the reporter’s story.

It was further reported that after this woman’s C-section, she was returned to the operating room. It can only be assumed that was done to stop bleeding. The good news is that the woman survived the surgery. But readers should be told that a return to the operating room to stop bleeding is very unusual. A C-section is a major surgery, but not a complicated surgery. A return to the operating room should not happen often. I always advise my readers to ask their obstetrician how many maternal deaths they have had and how many C-sections they have performed. If the numbers are higher than average, I suggest my readers look for another obstetrician. So, the story is not complete without a reason for the patient’s return to the operating room.

A couple weeks later this same patient had trouble with more pain and was worried about her incision. She went to see somebody, but again we aren’t told what kind of caregiver she saw. This person she saw told her the incision looked great even thought she was in pain. We aren’t told if the patient had a temperature, her white blood count, or whether an ultrasound was even done.  Missing an infection like this is simply inexcusable. The serious infection is deep, around muscles and fascia. Although sometimes exterior skin can be involved, signs of infection might not always be superficial, but can certainly be identified when firmness and pain are present.

Believe it or not, infection is the second cause of pregnancy-related death in the U.S. A deep infection can be serious because such an infection can spread to fascia (the tarp-like connective tissue surrounding muscle) which can lead to necrotizing fasciitis.  This kind of infection is complicated to treat because fascia, unlike muscle and skin, has no blood supply itself. The tissue survives by receiving nutrients and oxygen from the muscle beside it. So, antibiotics won’t help dead fascia. Necrotizing fasciitis is the reason that women can die from an episiotomy. In the U.S. there is no excuse to die from a pregnancy-related infection. We have good and available antibiotics to save a life if the correct diagnosis is made at the correct time.

The very next day, the patient went to labor and delivery and was found to be septic, having an overwhelming circulating blood infection. When it comes to various ways to prevent missing infection, it is clear that patients will fall through the cracks if there are lots of doctors taking care of the different hospitalizations, especially if these occur at more than one hospital. Did the patient ever see the original doctor or even the same doctor more than once? We aren’t told in the story what healthcare providers she saw and where. This is an important part of the story to allow readers to determine what caused the dismissiveness of the patient’s symptoms.

Today, rather than one or two doctors taking care of a patient as once was the case, continuity of care has been replaced with fragmentation of care. Without a personal relationship with the patient, the doctor doesn’t know the patient’s history and has no partnership with the patient. This is a major cause of dismissiveness. The provider has no partnership with the patient so doesn’t really have any investment in listening to the patient, or possibly even care.

Listening is easier and better if you know the patient and even better if you have a partnership with the patient.

There are some naive folks who think that 200 pages of electronic medical record (EMR) confetti can replace a good relationship between provider and patient or a good written paper record. News bulletin—the EMR can’t replace this relationship.

Nothing can replace the care that you will get from the doctor with whom you have a partnership. Somebody who will take personal responsibility for a good outcome. The movement to replace primary care doctors with teams of providers the patient doesn’t know is rotten to the core—destroying the lifesaving relationships between primary care doctors and the patients. I recommend patients find a primary care doctor and pass by the unknown providers who won’t take the time to listen to their concerns. You may be fortunate enough to live in an area with a Direct Primary Care physician.

Direct Primary Care is not concierge medicine, although critics like to pretend it is.  In many cases, the cost of Direct Primary Care is less than rapidly rising healthcare insurance.

Please, reporters, add these seemingly small details to your stories to help readers understand the causes of the dismissiveness reported by pregnant women. Women need this information to avoid finding themselves in a similar position.