Stories From the Wards: Lesson #1
Throughout my time in medical school, particularly during my clinical years (years 3 and 4), I started to see first hand the negative impacts that chronic diseases carries not just on our health at the individual level, but on our healthcare system as a whole. One example that comes to mind occurred on the first day of my inpatient medicine rotation. The story went something like this- my attending physician instructed me to go see “an admission” in the emergency room. I started by reviewing the patients chart, list of current medical conditions, current medications and any prior admission notes to get an idea for what I was walking into.
The patient was a gentleman in his fifties with a history of type 2 diabetes, hypertension (high blood pressure), hyperlipidemia (elevated triglycerides and/or cholesterol), obesity, and congestive heart failure. He was last seen two weeks prior for a congestive heart failure exacerbation, at which time his heart was failing, leading to a back up of fluid into his lungs (causing shortness of breath) and ultimately his lower extremities (causing pitting edema). In other words, this was not a healthy patient. He had severe metabolic syndrome and heart failure requiring a hospital admission just two weeks prior. And sadly, now he was back again.
As I prepared to visit with the patient and his family, I spoke with his nurse outside the room, who stated, “he’s back again with dyspnea and bilateral pitting edema. We already have Lasix (a diuretic) up and running and I have him on 3% oxygen via a nasal cannula. Says he didn’t follow up with his cardiologist because he “felt better” after his last admission.” As I entered the room, I introduced myself as a third-year medical student and explained that I was here to get a history and physical exam that I would then present to my attending physician. I then asked for permission to proceed at which time the patient, who appeared in significant distress, nodded that it was okay.
I then engaged in a discussion with the patient and his wife regarding the current symptoms- severe shortness of breath, dry cough, severe fatigue, and swelling of both legs. They stated that after his visit two weeks ago, after which he failed to begin taking the medications prescribed at his discharge. Further, he did not obtain follow-up with a cardiologist or primary care provider as recommended. When I asked why, they explained that they didn’t see any reason as they thought he “was cured.” However, the realty was, he was far from cured. He was just unaware of the chronicity of his medical conditions.
After he was stabilized and admitted to the hospital for additional care and observation, I was tasked with following up with him throughout his stay. As he remained clinically stable in terms of his laboratory parameters, fluid, and cardiorespiratory status, I decided to use my visits with him to discuss his care in more detail (one of the perks of being a medical student, we have the time to do this!).
Over the next few days, he emphasized to me a want to improve his health status and avoid having to come back to the hospital. He described a very poor diet (his A1c was 7.9% during his admission), no physical activity, and heavy alcohol use. I remember him saying, “what do I have to do to make sure this doesn’t happen again?” With the permission of my attending, I took the time to outline a plan with he and his wife. First, he would follow-up with his PCP and Cardiologist to make sure he was medically optimized and that it would be safe for him to exercise. Second, he would work to prioritize a whole-food diet and avoid alcohol, sugar-sweetened beverages, and fast food. Lastly, he would slowly implement walking into his daily schedule, starting with just 10-minutes of continuous walking, 3 times per week with a goal of eventually achieving 60-90 minutes per week.
You may be asking yourself, what makes you think he listened to you? To that, I will say that in medicine, patients who understand their care plan and believe in it are much more likely to adhere. In addition to the plan, I took (and had) the time to discuss how all of these changes will improve his health. We discussed the following:
Dietary improvement: will likely decrease his total sodium intake (beneficial for hypertension), improve his blood glucose levels (lower his A1c, reduce potential complications of diabetes if A1c goes below 7%), improve his cholesterol and triglyceride levels.
Physical Activity: will improve his cardiovascular fitness, blood glucose, blood pressure, lipid profile and aid in weight loss.
Alcohol avoidance: will improve his blood glucose control, sleep, and cardiac function (excess alcohol can cause a dilated cardiomyopathy).
While I will never know if this patient truly benefited from our discussion, I will venture to say that he did, at least I hope so.
The concluding point that I want you to take from this story is that we are in the position to make an effort to implement lifestyle changes BEFORE chronic diseases begin to develop. Engaging in physical activity, making mindful nutritional choices, achieving adequate sleep and stress reduction strategies are all aspects of our health that our under our direct control and part of our toolbox to extend our healthspan.