Chapter 10 of 27
An 82 year old male patient from Montreal was failing. He was up all night with severe pain. He was depressed. He was eating poorly. He was confused. He had a low red cell blood count and an ESR (an inflammatory index) of 90. It should be less than 20. His wife was exhausted caring for him.
There were three specialists and a family doctor taking care of this patient. None of the doctors were discussing the case. There was no communication and no collaboration. All the prior imaging studies were normal. The doctors felt confident that there was nothing wrong. There was ageism in their decision making.
At the outset, none of the doctors would co-operate with RCM's medical case managers. In fact, the doctors rejected a virtual case conference with everyone on the telephone including the family members.
It took persistence to finally gain the confidence of the four doctors. This came about when RCM's medical director ordered a PET/CT study. The study showed some abnormalities involving the patient's heart valves. When the doctors saw the abnormalities noted on the PET/CT report they started to think about what diseases they might have missed.
This new evidence allowed us to organize a case conference with the doctors, the medical case manager at RCM and the family members. This was a very valuable experience because the doctors were able to focus on the real problem that was indicated on the PET/CT.
Eventually, the patient was found to have infected heart valves and a brain abscess (infection). A cardiovascular surgeon in Montreal assessed the case. In his opinion, the mortality rate with surgery would have been over 80%. RCM also retained a cardiovascular surgeon for an independent opinion. RCM's surgeon advised against operating. The family and the team in Montreal chose not to operate.
The patient had three months of continuous IV antibiotics. The result was a dramatic improvement and resolution of the symptoms. The patient was driving again and back visiting his office and attending family events.
It is said that the only thing that doctors in hospitals share is the elevators. The objective of the "Deep Dive" process is to encourage collaboration and open and honest communication.
RCM uses a secure e-record that is shared by all the team members (RCM's medical case manager, RCM's nurse case manager, RCM's clinical researchers, the specialists and the family). Everyone is on the same page. As new information emerges, it is added to the e-record and notification is sent to the team members that it has been added.
The virtual case conference is an excellent way to organize the team and encourage collaboration. The virtual case conference is a very useful way to start the "Deep Dive" process. Each team member participates and the objectives of the team are articulated. The team members engage in the "Deep Dive" process and are united in their shared objectives. The family participates in this process and are equal partners in the decision making process.