A Patient is Not a Shunt

Some people may tell you that health care IT will solve many of the quality and cost problems in health care.

I don’t believe them.

I know a 70-year old man named Carlos (not his real name) who was hospitalized following a bout of hydrocephalus.  Hydrocephalus is a build-up of fluid in the skull, which affects the brain.  Among other things, people with hydrocephalus can be confused, irritable, and nauseous.  Carlos had all of these symptoms.

Carlos’ problem was fixable by inserting a special kind of drain in his head called a “shunt.”  This kind of shunt is, essentially, a series of catheters that runs from the brain into the abdomen, and which drain the excess fluid.  You can’t see it from the outside, so it’s meant to stay inside of you for a very long time.

For a week after Carlos’ shunt was installed, his symptoms completely disappeared.  But they soon started to re-emerge.  Worried, his family took him to the hospital.  Doctors found that his hydrocephalus was back – the shunt wasn’t draining properly.  They admitted him to the hospital, and the next day they put in a new shunt.  The surgery went well.

But again, about a day later, he started to have the same kinds of symptoms.  The doctors sent him for a CT scan, which showed, to their surprise, no problems with the shunt.  Unsure of what to do, they decided to wait and see if the symptoms resolved.  It was possible, they thought, that the symptoms were from the quick drainage of fluid through the shunt.

A doctor friend (call him Lou, although that’s not his name) happened to be visiting while this was going on.  Lou knew that Carlos had been on certain medications for a number of years.

“Has he been getting those medications in the days he’s been in the hospital?”  he asked the attending physician.

“I don’t know,” said the doctor, who went to check the hospital’s electronic medical record system.  “The meds are listed here, but it doesn’t look like he has been getting them.”

It wasn’t entirely shocking, since Carlos had been in and out of surgery.  Still, it was curious.  “What are you getting at?” asked the doctor.

Lou pulled out his iPhone, and looked up the symptoms of withdrawal from the medications Carlos was taking.  He showed them to the attending doctor:  confusion, irritability, nausea.  Very much what they were seeing and trying to explain as having to do with the shunt.

The attending spoke with the other physicians treating Carlos, and decided to put Carlos back on the medications.  His symptoms went away a short time after that.

One doctor I talked to about this story told me the doctors did the right thing.  Carlos had a history of hydrocephalus and problems with his shunt.  It made sense to rule out issues with the shunt before looking for other answers.

But another doctor I spoke with didn’t agree.  Given that the shunt had just been replaced, it seemed premature to try to explain everything by looking for another defective shunt.  Instead, this doctor told me, someone should have taken a look at his history before sending him for another CT scan.  As this doctor put it, “a patient is not a shunt.”

Carlos’ story tells us something about health care information technology that we may not want to hear.

The IT systems in the hospital were mainly used to order the CT scan, and to keep track of…medications that weren’t being given.  The single most important piece of equipment in Carlos’ case was the brain of the doctor treating him. .

Being a good doctor means asking good questions.  Until a computer can do more than come up with good Jeopardy questions, we must realize that we are still reliant on human judgment, and human fallibility.

And we will be for a very long time.

Evan Falchuk is President and Chief Strategy Officer of Best Doctors, Inc. Prior to joining Best Doctors, Inc., in 1999, he was an attorney at the Washington, DC, office of Fried, Frank, Harris, Shriver and Jacobson, where he worked on SEC enforcement cases.

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