The December Dilemma

In December, I carry a cautionary tale about clinical decision making and allowing non-medical details in a patient’s presentation to overly influence the treatment plan.  It’s the December dilemma: When physicians work short-staffed to cover partners taking vacation, and patients beg to be discharged prematurely to not miss the holiday events or ignore concerning symptoms to avoid hospital admission entirely.

A review of MagMutual claims from 2013 to 2019 revealed a 9% increase of lawsuit/claim frequency stemming from events in December as compared to other months. Additionally, the data showed an increase in severity of outcomes, specifically death (21% increase), grave permanent (62% increase) and major permanent (46% increase). Specialties particularly affected include Emergency Medicine, Hospitalists, and Advanced Practice Clinicians.

An older but poignant case example: On a Christmas Eve before the advent of enoxaparin, a young woman was hospitalized for a below-the-knee DVT. The patient was a non-smoker and reported no significant medical history, except for use of oral contraceptives. The patient felt relatively well, missed her family and wanted to go home for the holiday.

At this time, the decision tree mandated an inpatient course of unfractionated heparin and warfarin until her INR was >2.0. There was no option to bridge. Her INR, unfortunately, was subtherapeutic at 1.6. A hypercoagulable panel had been sent, but the results would not be available for at least another week. The clot was substantial, but below the popliteal fossa. Her leg edema was modest and she was not short of breath. The patient pleaded with the physician to discharge her on unopposed warfarin. The physician was apprehensive – but rationalized that if the INR was 1.6 at discharge, it would very well be 1.8 by the morning. The physician sympathized with her subacute presentation and the holiday, and discharged her on coumadin without bridging.

Unfortunately, the patient’s hypercoagulable panel would have revealed an undiagnosed Protein C deficiency, which led to microthrombi in the cutaneous and subcutaneous tissues in her bilateral breasts that caused rapid discoloration, beginning with violaceous changes and evolving to frank dense eschars. The condition ultimately resulted in bilateral necrosis of her breast tissue in its entirety. The patient endured skin grafts and reconstructive surgery over the next several years. Not surprisingly, it also resulted in a substantial settlement on behalf of the treating physician.

While current pharmaceuticals make this particular clinical scenario less likely to occur, the concept of both physicians and patients changing their usual pattern of decision making based on a desire to remain out of the hospital or avoid seeking medical attention during the holidays is as relevant now as it was 30 years ago.  How often has a middle-aged patient with ample risk factors and symptoms worrisome for unstable angina presented to an Emergency Department to be “checked out” only to protest against recommendations to be admitted/observed in the hospital setting?  The anecdotal story of a high-risk patient being released for close follow-up or signing out AMA in favor of outpatient follow-up only to perish from their undiagnosed myocardial atherosclerosis is a common refrain in risk management literature. The temptation to acquiesce and change our medical recommendations or endorse a less safe or frankly unsafe discharge plan especially in the setting of a major holiday is real and a genuine liability.  

Given the above observations, we must remain vigilant to maintaining and adhering to the algorithms and standard of care to make the right choices for those who entrust us with the care of their health. This means making the best choice and offering the best recommendations for the good of our patients, especially when those choices are in conflict with our own personal desires or those of the patients themselves. 

Additional Recommendations and Best Practices:

• Reduce workload proactively by reducing elective admissions for the week prior to the holidays.
• Implement an escalation plan that involves either in-house consultants or an agreement with an outside hospital, including a plan for what to do if the first option is not available. This is especially critical when consultants are also working with reduced staff.
• Ensure adequate call coverage, and if there are gaps that require transfer to higher level of care, ensure the ER staff is aware of these gaps.
• Avoid short staffing during the holidays. 
• Physician mentors and leaders should socialize the concept of not changing practice patterns/remain vigilant to best practice algorithms during the holidays.