October 2015
To :
Dr. 1 Primary Care,
Dr. 2, Dermatologist, and
Dr. 3, Chiropractor,
CC:
Dr. 4,
Dr. 5
Dr. 6
7 Medical Group
Dr. 8,
Dr. 9,
Re: Sean J Oliver
First: This is to inform you that your patient, Sean J Oliver, born April 19, 1972, died on October 22, 2015, as a result of multiple myeloma. (Diagnosed Feb 2015 after ER visit of almost total incapacitation.)
Second: To the first three doctors: You had the opportunity to connect the dots early on in a disease process; but you didn’t. The opportunity for early detection and treatment was not given to Sean because of the poor communication I saw when I became involved in his care. I also work in health care so I could see that there really was poor communication – and not just between you three practitioners but in the hospital area too. How many of the hospital physicians who interacted with Sean kept you in the loop, communicating test results, asking for your feedback, etc? Which one of you asked who else was treating him for the same symptoms? And this is an industry that taunts patient centered care!
I will admit to you that when I saw Sean in December of 2014, when he came home for Christmas, I told him to get a new primary care MD and new dermatologist because neither of you were providing good care; you weren’t taking a serious look at him. Everyone who saw him here said something is seriously wrong; yet you didn’t take notice. Even previously when on July 3 2014, there was a radiology report by Dr. 10 and in bold letters was “MYLOMA IS A CONSIDERATION”. Did anyone pay attention?!!!!!! Why was there no follow up then????????????????
Yes, I realize Sean is a guy, unmarried, so no significant other to push you, and, guys will down play symptoms. I also realize I don’t have the whole story, however, I truly believe something was missed here. When what appears to be a healthy young man starts using a walking stick to get around all the time, gets seen multiple times for pain, gets x-rays showing multiple old fxs/demineralization, including multiple ER visits a few steps from your own door Dr. 1, and this person is on a biologic medication whose side effect is cancer of the blood forming organs, if you all had been in communication, some dots would have gotten connected and opportunity for earlier treatment would have existed.
Your world has become complex with all the new drugs, biologics and side effects. This means you have to be more informed, observant, and vigilant, and, work at connecting the dots! The compartmentalization in the health care industry of today is counterproductive to good patient care; it is not patient centered; it is shattered. No one takes responsibility for putting together the pieces; they only want to look at their one piece and treat one piece. They don’t look at the whole person and what the person looked and acted like last month/last visit. A small example of the disconnect in the system: Sean was in Methodist hospital in San Antonio for 7 days, confined to his bed and not one person (RN, MD, aide) offered or did or made sure mouth care happened – 7 days with no toothbrush! Yes, it is a little thing, but indicative of the big problem in health care today. Possibly the outcome in Sean’s case would not have been any different as the Myeloma was an aggressive form. However, if it could have been treated earlier, when Sean had more defenses, then further treatments might have been possible instead of the spiral of complications that prevented further treatments and Sean’s final hospice decision. I feel he wasn’t given the opportunity that he should have had in today’s health care.
If nothing else, I hope this makes you take a look at yourselves and how you look at test/x-ray results and what is recommended and that you might connect the dots the next time – and there probably has already been, and will be, a next time to save someone’s son/daughter.
Dr. 9, you can tell Dr. 11 (Myloma specialist) that he was way off on ‘Sean being able to wait’ until October to see him’.
I have left of MD names on purpose.