"I'll take my chances at home;
I'm not going back there. Last time when I had a stroke, they sent me home
without catching it, and when I had a blood clot in my leg, I waited seventeen
hours before being seen. I understand the risks, but I just don't feel safe
going back there," she said solemnly. Her face was pale but her expression
decisive. I looked down at the typed note in front of me - my clinical
assessment strongly suggested a heart attack in progress, but I couldn't be
certain without an electrocardiogram (ECG) and blood work. Instead of sending
her to the emergency room (ER) as I felt to be medically necessary, I respected
her wishes and via shared decision making devised a plan together to manage the
situation as an outpatient. This mostly involved me arranging follow up with
the pharmacist, urgent blood work, serial ECGs, an urgent cardiology consult,
and frequent phone calls with the patient.
I never expected the
Hippocratic oath I took all those years ago stating, "do no harm" to
become "mitigate the harm done by our healthcare system". From the
staggering wait times to medical errors/negligence, patients have become
increasingly reticent to go to the ER. There was always some hesitancy, but it
has only escalated since COVID. The fear of wait times, past negative
experiences, and mistrust are all reasons patients have cited when I have
advised them to seek emergency care.
In medicine we learned about
something called "the Swiss cheese model". This model represents the
various safety nets put in place to prevent adverse events from happening to
patients. Like lining up slices of Swiss cheese, the ideal scenario involves
the holes being staggered so that while an individual may pass through one or
two holes, they will eventually be caught by another layer. Redundancy in a
system is critical for safety. However, if the holes line up perfectly, a
person may pass through all of them without being caught and something bad may
happen. For example, imagine a medication error where a doctor prescribes an
antibiotic that a patient is allergic to. Ideally this should be caught by the
doctor re-reading their prescription. Yet if it is missed, the other barriers
in place include the pharmacist reviewing the prescription, and the nurse
cross-checking the medication before administration. On a more systemic level,
slices would include accessible primary care/walk-in clinics, abundance of
commonly used medications, and timely access to hospital care. Every time we
cut corners, another hole is added to that slice of cheese. Forced overtime for
nursing staff means more burnout and a higher number of patients assigned to
one nurse. Insufficient PREMs (permits doctors need to practice in a given
region in Quebec) in an area with high rates of doctors retiring means
decreased access to primary care. Inadequate ward staffing means less beds open
and longer wait times in the ER.
Not enough recognition is given
to the critical role family medicine doctors and other frontline workers play
in filling the holes of our Swiss cheese model. From catching a cancer on a
scan that was missed while a patient was in hospital to frequent follows ups
with the suicidal teen waiting to be seen in psychiatry despite repeated visits
to the ER, sometimes we are the only slice preventing an adverse event - an
overwhelming burden adding to the many reasons why primary care physicians are leaving
the field altogether.
The above scenarios do not
reflect negligence or incompetence on the part of any individual, but simply
exemplify the outcomes when healthcare professionals are overburdened and
forced to care for more patients than they can reasonably handle. Instead of
forcing primary care physicians to take on more patients or other band-aid
solutions that look good on paper, we need our government to work with us at
all levels of the healthcare system. Else the holes in our Swiss cheese will
only continue to grow until there is nothing left.
