Counseling Patients About Their Chronic Diseases

The recently instituted 30-hour-shift "work restrictions" placed on medical residents have created a need for "dayfloat" services to safeguard potentially unsafe handoffs in patient care and help residents adhere to duty hour limits. The past two weeks I've been the dayfloat resident for the cardiology inpatient service. 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 low stress rotation, as they go, but because I "float" from one team to another without patients of my own, it can be hard to find meaning in the work.

Towards the end of my two week rotation, I was paged 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 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. This non-adherence is a constant source of angst for health care providers, who are often frustrated that patients don't take better care of themselves.

As I walked into the patient's room, I prepared myself to answer the typical questions families ask: "What did the test show?", "Did she have a heart attack?", "When can he go home?" But Mrs. FN's husband had a different set of concerns. He wanted to talk to me about why his wife's legs were swollen. The swelling was making it difficult for her to walk, and taking long walks together was their favorite pastime. I explained that the swelling, or edema, was due to her heart failure. Whenever her heart failure acted up, so would the swelling. I was planning on leaving it at that but Mr. FN wanted more. He wanted to know how the swelling got there in the first place.

My gut reaction was to respond that it's because she isn't taking her medications or doing what she is supposed to do. But putting my own frustrations aside, and sensing a teachable moment, 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, the kidneys start holding onto salt and fluid. The more fluid 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. Finally, I tied this back into his major concern by pointing out that in the process of building up fluid, patients' legs get swollen, causing some people to have a hard time getting around.

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 for example your wife's lisinopril medication, which blocks 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 pretty much only left room for home cooked meals.

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 education about heart failure, but the more I thought about it, the more I realized how this 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 are started on 3 to 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 clinic, where this patient would be seen next, the cardiologist is often busy piecing together the history from the patient and scattered hospital records. Most of his or her remaining time is spent on changing medications and filling out prescriptions, not 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 turns out that basic health education is not so basic afterall. Our health systems are better at getting patients stress tests and cardiac catherizations than educating them about their diseases and how to keep themselves healthy and out of the hospital. 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.

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Copyright Shantanu Nundy, M.D.

If you enjoyed this post, please visit Dr. Nundy's web site BeyondApples or read his book, Stay Healthy At Every Age.